| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
85 |
69 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
680 |
678 |
$27K |
| D1110 |
Prophylaxis - adult |
217 |
215 |
$9K |
| D2952 |
|
66 |
53 |
$6K |
| D0330 |
Panoramic radiographic image |
146 |
145 |
$5K |
| D0274 |
Bitewings - four radiographic images |
180 |
180 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
867 |
856 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
704 |
690 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
171 |
170 |
$1K |