| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
266 |
198 |
$139K |
| D1110 |
Prophylaxis - adult |
820 |
810 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
588 |
584 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
149 |
149 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
568 |
536 |
$6K |
| D0274 |
Bitewings - four radiographic images |
393 |
388 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
818 |
803 |
$4K |
| D2950 |
|
59 |
38 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
101 |
100 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
100 |
100 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
50 |
49 |
$2K |
| D1120 |
Prophylaxis - child |
19 |
16 |
$585.00 |