| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
39 |
33 |
$3K |
| D1110 |
Prophylaxis - adult |
65 |
65 |
$2K |
| D0274 |
Bitewings - four radiographic images |
50 |
50 |
$964.90 |
| D0120 |
Periodic oral evaluation - established patient |
50 |
50 |
$948.20 |
| D0220 |
Intraoral - periapical first radiographic image |
78 |
76 |
$692.40 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
13 |
$345.90 |
| D0230 |
Intraoral - periapical each additional radiographic image |
72 |
70 |
$320.30 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
15 |
$270.50 |