| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9430 |
|
1,175 |
1,068 |
$36K |
| D4910 |
|
238 |
238 |
$17K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
36 |
28 |
$17K |
| D2740 |
Crown - porcelain/ceramic |
18 |
13 |
$9K |
| D1110 |
Prophylaxis - adult |
85 |
85 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
71 |
71 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
311 |
304 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
58 |
58 |
$4K |
| D4341 |
|
44 |
12 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
594 |
350 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
164 |
160 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
32 |
32 |
$1K |
| D2954 |
|
14 |
13 |
$1K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
13 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$280.80 |
| D1320 |
|
13 |
13 |
$97.50 |