| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
316 |
315 |
$17K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
244 |
142 |
$15K |
| D2740 |
Crown - porcelain/ceramic |
22 |
12 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
199 |
199 |
$9K |
| D1110 |
Prophylaxis - adult |
67 |
66 |
$5K |
| D2140 |
|
85 |
43 |
$4K |
| D2160 |
|
40 |
27 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
802 |
324 |
$3K |
| D0274 |
Bitewings - four radiographic images |
86 |
86 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
53 |
53 |
$1K |
| D1120 |
Prophylaxis - child |
28 |
28 |
$810.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
28 |
28 |
$216.00 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$168.00 |