| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
673 |
305 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
784 |
779 |
$31K |
| D1110 |
Prophylaxis - adult |
349 |
345 |
$26K |
| D1120 |
Prophylaxis - child |
798 |
793 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,285 |
873 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
374 |
372 |
$21K |
| D0274 |
Bitewings - four radiographic images |
615 |
608 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,143 |
1,134 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
172 |
172 |
$8K |
| D2140 |
|
110 |
55 |
$6K |
| D2160 |
|
69 |
37 |
$5K |
| D0350 |
|
380 |
217 |
$3K |
| D1351 |
Sealant - per tooth |
77 |
30 |
$2K |
| D0272 |
Bitewings - two radiographic images |
64 |
64 |
$740.00 |