| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
82 |
81 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
46 |
25 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
58 |
58 |
$834.20 |
| D0272 |
Bitewings - two radiographic images |
48 |
48 |
$648.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
44 |
43 |
$576.90 |
| D2140 |
|
27 |
18 |
$561.60 |
| D1999 |
|
78 |
68 |
$551.38 |
| D1120 |
Prophylaxis - child |
32 |
31 |
$486.00 |
| D0120 |
Periodic oral evaluation - established patient |
39 |
38 |
$434.46 |
| D7140 |
Extraction, erupted tooth or exposed root |
15 |
12 |
$335.50 |
| D0220 |
Intraoral - periapical first radiographic image |
50 |
50 |
$258.20 |
| D0230 |
Intraoral - periapical each additional radiographic image |
52 |
48 |
$184.50 |