| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
182 |
108 |
$11K |
| D1120 |
Prophylaxis - child |
165 |
163 |
$7K |
| D1110 |
Prophylaxis - adult |
144 |
144 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
268 |
266 |
$5K |
| D0330 |
Panoramic radiographic image |
124 |
121 |
$5K |
| D0274 |
Bitewings - four radiographic images |
114 |
114 |
$3K |
| D1206 |
Topical application of fluoride varnish |
191 |
188 |
$3K |
| D2140 |
|
50 |
39 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
42 |
41 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
27 |
26 |
$262.92 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$229.32 |