| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
152 |
55 |
$14K |
| D1351 |
Sealant - per tooth |
365 |
63 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
161 |
160 |
$5K |
| D1110 |
Prophylaxis - adult |
88 |
87 |
$4K |
| D1206 |
Topical application of fluoride varnish |
108 |
108 |
$4K |
| D0274 |
Bitewings - four radiographic images |
104 |
103 |
$4K |
| D1120 |
Prophylaxis - child |
77 |
77 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
23 |
15 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
39 |
39 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
87 |
60 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
30 |
30 |
$1K |
| D9110 |
|
13 |
12 |
$723.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$560.00 |
| D1310 |
|
13 |
13 |
$110.00 |