| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
251 |
251 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
255 |
254 |
$4K |
| D1120 |
Prophylaxis - child |
205 |
204 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
198 |
197 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
255 |
255 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
24 |
24 |
$876.99 |
| D0272 |
Bitewings - two radiographic images |
60 |
59 |
$822.46 |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
30 |
24 |
$818.43 |
| D2140 |
|
37 |
25 |
$781.92 |
| D7140 |
Extraction, erupted tooth or exposed root |
27 |
13 |
$638.86 |
| D1999 |
|
106 |
92 |
$612.85 |
| D0220 |
Intraoral - periapical first radiographic image |
90 |
85 |
$444.80 |
| D0230 |
Intraoral - periapical each additional radiographic image |
77 |
76 |
$391.00 |