| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
65 |
52 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
55 |
36 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
37 |
37 |
$3K |
| D1120 |
Prophylaxis - child |
59 |
59 |
$2K |
| D2140 |
|
33 |
28 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
61 |
61 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
56 |
56 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
33 |
33 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
100 |
97 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$897.00 |
| D1110 |
Prophylaxis - adult |
17 |
17 |
$864.80 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$407.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
18 |
14 |
$152.40 |