| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
237 |
161 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
392 |
366 |
$8K |
| D0330 |
Panoramic radiographic image |
278 |
271 |
$6K |
| D1110 |
Prophylaxis - adult |
233 |
216 |
$6K |
| D2160 |
|
84 |
69 |
$5K |
| D1120 |
Prophylaxis - child |
81 |
72 |
$3K |
| D0274 |
Bitewings - four radiographic images |
138 |
118 |
$2K |
| D1351 |
Sealant - per tooth |
27 |
16 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
24 |
14 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
83 |
80 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
168 |
143 |
$909.80 |
| D2161 |
|
12 |
12 |
$754.65 |
| D0230 |
Intraoral - periapical each additional radiographic image |
159 |
136 |
$642.20 |
| D1206 |
Topical application of fluoride varnish |
15 |
14 |
$338.00 |