| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
896 |
890 |
$80K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
580 |
380 |
$68K |
| D0120 |
Periodic oral evaluation - established patient |
890 |
887 |
$63K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
919 |
599 |
$61K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
794 |
785 |
$52K |
| D0210 |
Intraoral - complete series of radiographic images |
927 |
918 |
$43K |
| D7140 |
Extraction, erupted tooth or exposed root |
400 |
135 |
$23K |
| D1120 |
Prophylaxis - child |
401 |
401 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,464 |
849 |
$14K |
| D0274 |
Bitewings - four radiographic images |
570 |
568 |
$12K |
| D2140 |
|
195 |
149 |
$10K |
| D2160 |
|
70 |
55 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
354 |
354 |
$5K |
| D1351 |
Sealant - per tooth |
55 |
14 |
$2K |
| D2331 |
|
18 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$144.00 |