| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2751 |
Crown - porcelain fused to predominantly base metal |
258 |
206 |
$123K |
| D0120 |
Periodic oral evaluation - established patient |
1,812 |
1,807 |
$102K |
| D1110 |
Prophylaxis - adult |
1,016 |
1,013 |
$89K |
| D0230 |
Intraoral - periapical each additional radiographic image |
13,484 |
2,388 |
$54K |
| D1120 |
Prophylaxis - child |
1,232 |
1,232 |
$47K |
| D9430 |
|
1,302 |
1,198 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
583 |
583 |
$37K |
| D0272 |
Bitewings - two radiographic images |
1,940 |
1,936 |
$23K |
| D0210 |
Intraoral - complete series of radiographic images |
463 |
463 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,255 |
1,255 |
$15K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
97 |
68 |
$7K |
| D2954 |
|
43 |
41 |
$5K |
| D2140 |
|
56 |
36 |
$3K |
| D1351 |
Sealant - per tooth |
70 |
15 |
$2K |
| D0330 |
Panoramic radiographic image |
29 |
29 |
$870.00 |
| D0220 |
Intraoral - periapical first radiographic image |
40 |
39 |
$480.00 |