| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
169 |
142 |
$79K |
| D0120 |
Periodic oral evaluation - established patient |
1,408 |
1,406 |
$73K |
| D1120 |
Prophylaxis - child |
1,387 |
1,380 |
$51K |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,849 |
2,163 |
$46K |
| D2140 |
|
586 |
341 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
376 |
375 |
$25K |
| D1351 |
Sealant - per tooth |
955 |
287 |
$23K |
| D0272 |
Bitewings - two radiographic images |
1,770 |
1,765 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,295 |
1,289 |
$14K |
| D0350 |
|
380 |
203 |
$3K |
| D4341 |
|
43 |
13 |
$3K |
| D9430 |
|
86 |
83 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
190 |
188 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
24 |
24 |
$1K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$990.00 |