| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
434 |
269 |
$206K |
| D1110 |
Prophylaxis - adult |
872 |
872 |
$72K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
954 |
954 |
$60K |
| D0210 |
Intraoral - complete series of radiographic images |
1,286 |
1,284 |
$58K |
| D9430 |
|
1,201 |
1,174 |
$37K |
| D2954 |
|
155 |
106 |
$16K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
107 |
43 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
707 |
697 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
132 |
132 |
$8K |
| D1120 |
Prophylaxis - child |
65 |
65 |
$2K |
| D0274 |
Bitewings - four radiographic images |
103 |
103 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
263 |
140 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
27 |
27 |
$160.00 |