| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
25 |
18 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
177 |
175 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
126 |
126 |
$6K |
| D9430 |
|
176 |
127 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
35 |
35 |
$2K |
| D2954 |
|
15 |
13 |
$2K |
| D1120 |
Prophylaxis - child |
29 |
29 |
$840.00 |
| D0274 |
Bitewings - four radiographic images |
26 |
26 |
$561.60 |
| D1208 |
Topical application of fluoride, excluding varnish |
48 |
47 |
$394.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
98 |
45 |
$358.05 |