| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
110 |
57 |
$8K |
| D1110 |
Prophylaxis - adult |
101 |
100 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
162 |
158 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
135 |
132 |
$3K |
| D0272 |
Bitewings - two radiographic images |
129 |
125 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
218 |
154 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
168 |
162 |
$2K |
| D1120 |
Prophylaxis - child |
63 |
60 |
$2K |
| D2140 |
|
18 |
12 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
22 |
22 |
$643.50 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$311.08 |