| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
205 |
205 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
123 |
23 |
$10K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
38 |
23 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
37 |
37 |
$3K |
| D2160 |
|
27 |
18 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
58 |
58 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
33 |
33 |
$1K |
| D0274 |
Bitewings - four radiographic images |
31 |
31 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
20 |
20 |
$840.00 |
| D0220 |
Intraoral - periapical first radiographic image |
44 |
43 |
$748.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
83 |
33 |
$558.00 |