| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,058 |
471 |
$56K |
| D0120 |
Periodic oral evaluation - established patient |
1,873 |
1,871 |
$48K |
| D1110 |
Prophylaxis - adult |
888 |
887 |
$40K |
| D1120 |
Prophylaxis - child |
836 |
835 |
$33K |
| D1206 |
Topical application of fluoride varnish |
1,333 |
1,332 |
$22K |
| D0274 |
Bitewings - four radiographic images |
883 |
883 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
17 |
13 |
$1K |
| D2160 |
|
25 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
117 |
104 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
27 |
27 |
$891.00 |
| D4910 |
|
12 |
12 |
$756.00 |
| D1999 |
|
25 |
21 |
$168.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$160.00 |