| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
274 |
150 |
$130K |
| D4910 |
|
983 |
968 |
$75K |
| D9430 |
|
1,930 |
1,622 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
813 |
813 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
499 |
498 |
$28K |
| D2954 |
|
219 |
115 |
$23K |
| D1120 |
Prophylaxis - child |
330 |
329 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
258 |
257 |
$12K |
| D4341 |
|
151 |
44 |
$11K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
17 |
12 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
463 |
463 |
$6K |
| D0274 |
Bitewings - four radiographic images |
294 |
293 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
725 |
348 |
$3K |
| D0330 |
Panoramic radiographic image |
31 |
31 |
$775.00 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$480.00 |