| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
138 |
92 |
$66K |
| D0120 |
Periodic oral evaluation - established patient |
490 |
487 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
329 |
329 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,909 |
751 |
$15K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
219 |
137 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
226 |
226 |
$11K |
| D1110 |
Prophylaxis - adult |
118 |
118 |
$9K |
| D1120 |
Prophylaxis - child |
239 |
235 |
$8K |
| D9430 |
|
206 |
170 |
$7K |
| D0272 |
Bitewings - two radiographic images |
350 |
347 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
229 |
202 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
223 |
218 |
$2K |
| D0350 |
|
143 |
76 |
$1K |
| D0274 |
Bitewings - four radiographic images |
41 |
40 |
$864.00 |