| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
393 |
204 |
$187K |
| D1110 |
Prophylaxis - adult |
1,650 |
1,648 |
$136K |
| D4910 |
|
1,059 |
1,051 |
$81K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,007 |
999 |
$62K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
471 |
228 |
$54K |
| D4341 |
|
752 |
224 |
$48K |
| D5750 |
|
126 |
126 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,564 |
1,358 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
1,702 |
1,666 |
$20K |
| D2954 |
|
176 |
112 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
203 |
203 |
$17K |
| D5110 |
|
25 |
25 |
$16K |
| D1206 |
Topical application of fluoride varnish |
788 |
787 |
$14K |
| D5751 |
|
61 |
61 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
144 |
142 |
$7K |
| D9110 |
|
18 |
18 |
$1K |
| D0272 |
Bitewings - two radiographic images |
29 |
29 |
$316.00 |