| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
156 |
107 |
$8K |
| D2140 |
|
148 |
95 |
$6K |
| D1120 |
Prophylaxis - child |
250 |
247 |
$5K |
| D1206 |
Topical application of fluoride varnish |
324 |
321 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
243 |
242 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
40 |
26 |
$2K |
| D0274 |
Bitewings - four radiographic images |
79 |
79 |
$2K |
| D1110 |
Prophylaxis - adult |
44 |
44 |
$2K |
| D0272 |
Bitewings - two radiographic images |
153 |
150 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
35 |
35 |
$922.25 |