| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
137 |
71 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
132 |
49 |
$9K |
| D1110 |
Prophylaxis - adult |
162 |
162 |
$7K |
| D2140 |
|
111 |
58 |
$6K |
| D0330 |
Panoramic radiographic image |
91 |
91 |
$4K |
| D0274 |
Bitewings - four radiographic images |
134 |
134 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
148 |
141 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
84 |
84 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
69 |
69 |
$2K |
| D2160 |
|
19 |
15 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
45 |
45 |
$481.95 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$318.60 |