| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2750 |
|
240 |
191 |
$134K |
| D1110 |
Prophylaxis - adult |
1,743 |
1,736 |
$77K |
| D0120 |
Periodic oral evaluation - established patient |
1,591 |
1,586 |
$35K |
| D0210 |
Intraoral - complete series of radiographic images |
763 |
757 |
$32K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
73 |
47 |
$31K |
| D0274 |
Bitewings - four radiographic images |
562 |
562 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,134 |
1,123 |
$12K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
170 |
121 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
665 |
640 |
$7K |
| D1320 |
|
764 |
761 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
77 |
77 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
117 |
117 |
$1K |
| D0160 |
|
28 |
28 |
$690.20 |
| D1208 |
Topical application of fluoride, excluding varnish |
17 |
17 |
$185.30 |