| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
396 |
281 |
$188K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
911 |
911 |
$60K |
| D1351 |
Sealant - per tooth |
951 |
193 |
$36K |
| D1120 |
Prophylaxis - child |
530 |
529 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
302 |
301 |
$24K |
| D4910 |
|
308 |
308 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,360 |
981 |
$22K |
| D0274 |
Bitewings - four radiographic images |
620 |
620 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
782 |
782 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
184 |
184 |
$9K |
| D1320 |
|
379 |
379 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
359 |
358 |
$4K |
| D0350 |
|
443 |
279 |
$4K |
| D1110 |
Prophylaxis - adult |
42 |
42 |
$4K |
| D1310 |
|
26 |
26 |
$1K |
| D9430 |
|
28 |
28 |
$896.00 |
| D0272 |
Bitewings - two radiographic images |
30 |
30 |
$360.00 |