| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
301 |
301 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
306 |
306 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
175 |
175 |
$3K |
| D0272 |
Bitewings - two radiographic images |
150 |
150 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
77 |
42 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
83 |
44 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
129 |
129 |
$2K |
| D2140 |
|
71 |
35 |
$1K |
| D1120 |
Prophylaxis - child |
69 |
69 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
81 |
81 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
193 |
192 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$152.88 |