| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
914 |
505 |
$434K |
| D4910 |
|
2,310 |
2,286 |
$176K |
| D1110 |
Prophylaxis - adult |
2,092 |
2,086 |
$173K |
| D4341 |
|
1,792 |
509 |
$117K |
| D5750 |
|
475 |
471 |
$92K |
| D0120 |
Periodic oral evaluation - established patient |
1,667 |
1,660 |
$90K |
| D5751 |
|
346 |
343 |
$67K |
| D2954 |
|
592 |
356 |
$62K |
| D5761 |
|
308 |
304 |
$58K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
570 |
570 |
$36K |
| D1206 |
Topical application of fluoride varnish |
2,226 |
2,221 |
$35K |
| D0210 |
Intraoral - complete series of radiographic images |
744 |
742 |
$32K |
| D5110 |
|
26 |
26 |
$16K |
| D4342 |
|
363 |
124 |
$13K |
| D5851 |
|
181 |
180 |
$13K |
| D5760 |
|
67 |
67 |
$13K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
79 |
40 |
$9K |
| D5850 |
|
115 |
113 |
$8K |
| D2920 |
|
164 |
118 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
539 |
502 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,219 |
369 |
$5K |
| D0274 |
Bitewings - four radiographic images |
15 |
15 |
$324.00 |