| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
1,054 |
658 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
1,313 |
1,313 |
$16K |
| D1110 |
Prophylaxis - adult |
785 |
784 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
269 |
269 |
$5K |
| D1120 |
Prophylaxis - child |
407 |
407 |
$4K |
| D0272 |
Bitewings - two radiographic images |
1,017 |
1,017 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
1,231 |
1,220 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,158 |
1,145 |
$4K |
| D9211 |
|
327 |
279 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
466 |
466 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
195 |
195 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
45 |
40 |
$2K |
| D2140 |
|
16 |
12 |
$382.00 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
12 |
12 |
$217.00 |
| D9110 |
|
16 |
16 |
$147.00 |