| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
210 |
186 |
$115K |
| D1110 |
Prophylaxis - adult |
1,098 |
1,098 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
1,207 |
1,207 |
$35K |
| D0140 |
Limited oral evaluation - problem focused |
572 |
566 |
$12K |
| D2954 |
|
87 |
78 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
1,778 |
1,704 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
180 |
180 |
$8K |
| D0274 |
Bitewings - four radiographic images |
636 |
636 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
120 |
120 |
$5K |
| D0330 |
Panoramic radiographic image |
139 |
139 |
$5K |
| D0350 |
|
24 |
24 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,100 |
1,095 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
95 |
95 |
$2K |
| D4355 |
|
15 |
15 |
$2K |
| D1120 |
Prophylaxis - child |
13 |
13 |
$540.00 |
| D9430 |
|
12 |
12 |
$300.00 |
| D0270 |
|
12 |
12 |
$60.00 |