| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
285 |
159 |
$136K |
| D1110 |
Prophylaxis - adult |
1,391 |
1,391 |
$111K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
752 |
752 |
$46K |
| D4910 |
|
587 |
587 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
654 |
654 |
$34K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,468 |
2,467 |
$32K |
| D0210 |
Intraoral - complete series of radiographic images |
651 |
651 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,455 |
758 |
$14K |
| D2952 |
|
66 |
50 |
$7K |
| D1320 |
|
592 |
591 |
$6K |
| D4341 |
|
82 |
26 |
$6K |
| D1120 |
Prophylaxis - child |
98 |
98 |
$3K |
| D0272 |
Bitewings - two radiographic images |
164 |
164 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
29 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
38 |
36 |
$456.00 |
| D0274 |
Bitewings - four radiographic images |
16 |
16 |
$345.60 |