| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
87 |
44 |
$7K |
| D1110 |
Prophylaxis - adult |
78 |
74 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
138 |
127 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
64 |
57 |
$2K |
| D0272 |
Bitewings - two radiographic images |
77 |
70 |
$2K |
| D1206 |
Topical application of fluoride varnish |
70 |
60 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
48 |
41 |
$836.05 |
| D1120 |
Prophylaxis - child |
20 |
16 |
$721.60 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$239.40 |