| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
1,057 |
634 |
$730K |
| D1110 |
Prophylaxis - adult |
3,886 |
3,886 |
$211K |
| D2954 |
|
964 |
587 |
$156K |
| D0120 |
Periodic oral evaluation - established patient |
4,341 |
4,341 |
$118K |
| D0274 |
Bitewings - four radiographic images |
4,068 |
4,067 |
$111K |
| D1120 |
Prophylaxis - child |
1,816 |
1,816 |
$77K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,104 |
2,104 |
$63K |
| D0210 |
Intraoral - complete series of radiographic images |
1,438 |
1,437 |
$47K |
| D3320 |
|
121 |
93 |
$39K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,636 |
1,636 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
207 |
130 |
$16K |
| D3310 |
|
56 |
24 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
199 |
116 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
600 |
600 |
$8K |
| D0272 |
Bitewings - two radiographic images |
296 |
296 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
322 |
322 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
48 |
38 |
$4K |
| D1206 |
Topical application of fluoride varnish |
133 |
133 |
$4K |
| D2140 |
|
13 |
12 |
$930.60 |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$601.60 |