| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
976 |
974 |
$81K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
117 |
72 |
$56K |
| D0120 |
Periodic oral evaluation - established patient |
1,117 |
1,114 |
$51K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,243 |
1,536 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
326 |
324 |
$19K |
| D0274 |
Bitewings - four radiographic images |
816 |
813 |
$17K |
| D1120 |
Prophylaxis - child |
453 |
452 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
266 |
266 |
$13K |
| D1206 |
Topical application of fluoride varnish |
715 |
706 |
$12K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
85 |
43 |
$6K |
| D2954 |
|
38 |
26 |
$4K |
| D0272 |
Bitewings - two radiographic images |
327 |
326 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
311 |
310 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$115.00 |
| D1999 |
|
18 |
18 |
$0.00 |