| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
14 |
12 |
$21K |
| D1110 |
Prophylaxis - adult |
396 |
396 |
$17K |
| D0274 |
Bitewings - four radiographic images |
575 |
575 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
485 |
485 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
565 |
564 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
183 |
183 |
$4K |
| D0330 |
Panoramic radiographic image |
66 |
66 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
41 |
41 |
$609.63 |
| D1208 |
Topical application of fluoride, excluding varnish |
46 |
46 |
$501.40 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$396.76 |