| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
103 |
47 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
192 |
190 |
$4K |
| D1110 |
Prophylaxis - adult |
226 |
224 |
$4K |
| D0274 |
Bitewings - four radiographic images |
318 |
316 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
149 |
149 |
$2K |
| D0330 |
Panoramic radiographic image |
134 |
134 |
$2K |
| D1120 |
Prophylaxis - child |
79 |
79 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
128 |
126 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
276 |
266 |
$945.00 |
| D0140 |
Limited oral evaluation - problem focused |
62 |
58 |
$868.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
180 |
176 |
$486.75 |