| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0230 |
Intraoral - periapical each additional radiographic image |
9,016 |
1,708 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
807 |
800 |
$39K |
| D0274 |
Bitewings - four radiographic images |
1,141 |
1,130 |
$24K |
| D1110 |
Prophylaxis - adult |
246 |
246 |
$22K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
42 |
27 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,302 |
1,291 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
205 |
204 |
$13K |
| D1120 |
Prophylaxis - child |
332 |
328 |
$10K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
59 |
29 |
$4K |
| D2954 |
|
21 |
14 |
$2K |
| D2140 |
|
41 |
15 |
$2K |
| D0272 |
Bitewings - two radiographic images |
52 |
52 |
$570.00 |