| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
35 |
28 |
$19K |
| D1110 |
Prophylaxis - adult |
190 |
190 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
276 |
276 |
$8K |
| D2954 |
|
58 |
42 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
47 |
30 |
$3K |
| D1120 |
Prophylaxis - child |
66 |
66 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
39 |
39 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
37 |
37 |
$2K |
| D0274 |
Bitewings - four radiographic images |
136 |
136 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
324 |
316 |
$2K |
| D1206 |
Topical application of fluoride varnish |
38 |
38 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
256 |
256 |
$903.00 |
| D0140 |
Limited oral evaluation - problem focused |
27 |
26 |
$324.00 |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$150.00 |