| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
523 |
348 |
$207K |
| D1110 |
Prophylaxis - adult |
4,597 |
4,595 |
$186K |
| D0120 |
Periodic oral evaluation - established patient |
5,346 |
5,345 |
$109K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,796 |
1,787 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
293 |
237 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,717 |
1,717 |
$15K |
| D2954 |
|
80 |
69 |
$7K |
| D0330 |
Panoramic radiographic image |
205 |
205 |
$6K |
| D2791 |
|
14 |
13 |
$4K |
| D0272 |
Bitewings - two radiographic images |
299 |
299 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
48 |
26 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
13 |
$1K |
| D0274 |
Bitewings - four radiographic images |
15 |
15 |
$294.22 |