| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
423 |
418 |
$29K |
| D1120 |
Prophylaxis - child |
143 |
140 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
143 |
138 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
52 |
26 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
77 |
25 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
55 |
53 |
$521.95 |
| D0274 |
Bitewings - four radiographic images |
306 |
301 |
$397.62 |
| D0120 |
Periodic oral evaluation - established patient |
387 |
384 |
$168.59 |
| D0220 |
Intraoral - periapical first radiographic image |
143 |
135 |
$9.22 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
99 |
98 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
401 |
396 |
$-64.28 |