| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
728 |
391 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
886 |
876 |
$44K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,057 |
1,646 |
$32K |
| D1120 |
Prophylaxis - child |
979 |
971 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
463 |
461 |
$27K |
| D1110 |
Prophylaxis - adult |
235 |
235 |
$21K |
| D2160 |
|
258 |
147 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
152 |
50 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
855 |
851 |
$8K |
| D0272 |
Bitewings - two radiographic images |
701 |
699 |
$8K |
| D0274 |
Bitewings - four radiographic images |
319 |
312 |
$6K |
| D0350 |
|
340 |
122 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
42 |
16 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
14 |
$140.00 |