| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
420 |
279 |
$10K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
115 |
59 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
369 |
243 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
289 |
191 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
490 |
357 |
$8K |
| D0274 |
Bitewings - four radiographic images |
135 |
96 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
32 |
14 |
$963.92 |
| D0220 |
Intraoral - periapical first radiographic image |
16 |
12 |
$114.17 |