| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
304 |
173 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
716 |
679 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
372 |
342 |
$14K |
| D0330 |
Panoramic radiographic image |
252 |
230 |
$13K |
| D1120 |
Prophylaxis - child |
525 |
486 |
$12K |
| D1206 |
Topical application of fluoride varnish |
749 |
697 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
155 |
58 |
$9K |
| D1351 |
Sealant - per tooth |
313 |
79 |
$8K |
| D1110 |
Prophylaxis - adult |
226 |
217 |
$8K |
| D0274 |
Bitewings - four radiographic images |
198 |
185 |
$5K |
| D2140 |
|
57 |
37 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
250 |
231 |
$3K |
| D0272 |
Bitewings - two radiographic images |
140 |
130 |
$2K |
| D2160 |
|
19 |
13 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
53 |
51 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
163 |
67 |
$2K |