| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
194 |
59 |
$84K |
| D1110 |
Prophylaxis - adult |
669 |
666 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
600 |
594 |
$14K |
| D0274 |
Bitewings - four radiographic images |
528 |
525 |
$11K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
67 |
37 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
649 |
499 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
396 |
394 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
105 |
105 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
51 |
51 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
26 |
26 |
$283.40 |