| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
391 |
198 |
$186K |
| D1110 |
Prophylaxis - adult |
746 |
734 |
$54K |
| D2954 |
|
389 |
199 |
$40K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,095 |
1,306 |
$28K |
| D2952 |
|
182 |
115 |
$18K |
| D4341 |
|
217 |
68 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,233 |
1,166 |
$14K |
| D9430 |
|
395 |
383 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
166 |
165 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
579 |
575 |
$7K |
| D3320 |
|
18 |
14 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
222 |
219 |
$4K |
| D0272 |
Bitewings - two radiographic images |
116 |
116 |
$1K |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$106.00 |