| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
20 |
12 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
740 |
675 |
$851.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
147 |
130 |
$697.00 |
| D9430 |
|
45 |
42 |
$633.93 |
| D1208 |
Topical application of fluoride, excluding varnish |
779 |
735 |
$545.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
905 |
804 |
$528.38 |
| D1120 |
Prophylaxis - child |
487 |
456 |
$385.00 |
| D0210 |
Intraoral - complete series of radiographic images |
141 |
131 |
$104.00 |
| D0274 |
Bitewings - four radiographic images |
313 |
287 |
$3.60 |
| D0272 |
Bitewings - two radiographic images |
15 |
12 |
$0.00 |
| D1330 |
|
267 |
245 |
$0.00 |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
22 |
12 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
31 |
24 |
$0.00 |