| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
29 |
25 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
301 |
286 |
$14K |
| D1110 |
Prophylaxis - adult |
135 |
135 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
174 |
174 |
$4K |
| D9110 |
|
90 |
88 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
450 |
434 |
$2K |
| D2954 |
|
16 |
13 |
$2K |
| D1206 |
Topical application of fluoride varnish |
30 |
30 |
$937.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
166 |
164 |
$711.59 |
| D0274 |
Bitewings - four radiographic images |
55 |
55 |
$660.34 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$585.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$350.00 |
| D0603 |
|
12 |
12 |
$120.00 |