| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
258 |
172 |
$156K |
| D1110 |
Prophylaxis - adult |
2,952 |
2,944 |
$127K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
770 |
585 |
$83K |
| D0120 |
Periodic oral evaluation - established patient |
2,747 |
2,742 |
$59K |
| D0274 |
Bitewings - four radiographic images |
2,619 |
2,619 |
$57K |
| D0220 |
Intraoral - periapical first radiographic image |
3,192 |
3,179 |
$34K |
| D2160 |
|
214 |
144 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,880 |
2,876 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
508 |
508 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
345 |
344 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
561 |
561 |
$6K |
| D2140 |
|
71 |
62 |
$6K |
| D1120 |
Prophylaxis - child |
146 |
146 |
$5K |