| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
73 |
66 |
$40K |
| D1110 |
Prophylaxis - adult |
754 |
754 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
572 |
572 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
205 |
205 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
320 |
320 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
165 |
164 |
$7K |
| D0274 |
Bitewings - four radiographic images |
478 |
478 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
596 |
594 |
$6K |
| D1120 |
Prophylaxis - child |
120 |
120 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
834 |
830 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
54 |
39 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
47 |
47 |
$1K |
| D9310 |
|
12 |
12 |
$240.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$130.00 |