| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
43 |
23 |
$3K |
| D0274 |
Bitewings - four radiographic images |
69 |
69 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
91 |
91 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
24 |
15 |
$2K |
| D1120 |
Prophylaxis - child |
48 |
48 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
41 |
41 |
$1K |
| D1110 |
Prophylaxis - adult |
23 |
23 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
30 |
29 |
$899.38 |
| D0120 |
Periodic oral evaluation - established patient |
38 |
38 |
$877.18 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$650.03 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
16 |
15 |
$442.06 |
| D0220 |
Intraoral - periapical first radiographic image |
24 |
24 |
$276.73 |