| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
333 |
169 |
$21K |
| D1120 |
Prophylaxis - child |
614 |
613 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
230 |
121 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
545 |
545 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,524 |
657 |
$11K |
| D2140 |
|
162 |
96 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
631 |
629 |
$6K |
| D0274 |
Bitewings - four radiographic images |
234 |
233 |
$4K |
| D0272 |
Bitewings - two radiographic images |
297 |
296 |
$3K |
| D1351 |
Sealant - per tooth |
127 |
44 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
67 |
66 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
125 |
124 |
$1K |
| D0350 |
|
188 |
117 |
$1K |