| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
545 |
235 |
$34K |
| D2160 |
|
353 |
171 |
$28K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
63 |
36 |
$27K |
| D1110 |
Prophylaxis - adult |
570 |
570 |
$25K |
| D0274 |
Bitewings - four radiographic images |
682 |
682 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
477 |
477 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
602 |
601 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
169 |
169 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
555 |
555 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
82 |
82 |
$2K |
| D2140 |
|
24 |
15 |
$987.36 |
| D1120 |
Prophylaxis - child |
26 |
26 |
$836.16 |
| D1208 |
Topical application of fluoride, excluding varnish |
73 |
73 |
$795.70 |