| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
103 |
53 |
$45K |
| D1110 |
Prophylaxis - adult |
637 |
636 |
$28K |
| D0274 |
Bitewings - four radiographic images |
528 |
528 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
380 |
380 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
485 |
485 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
144 |
144 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
492 |
478 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
30 |
13 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
59 |
59 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
87 |
87 |
$948.30 |