| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
128 |
56 |
$9K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
40 |
18 |
$5K |
| D2160 |
|
59 |
37 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
106 |
106 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
89 |
89 |
$4K |
| D2140 |
|
62 |
28 |
$3K |
| D1120 |
Prophylaxis - child |
85 |
84 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
639 |
146 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
90 |
89 |
$2K |
| D0350 |
|
209 |
83 |
$1K |
| D1110 |
Prophylaxis - adult |
35 |
35 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
117 |
116 |
$948.00 |
| D0274 |
Bitewings - four radiographic images |
50 |
50 |
$792.00 |
| D9430 |
|
25 |
24 |
$644.00 |
| D0220 |
Intraoral - periapical first radiographic image |
63 |
59 |
$620.00 |
| D0272 |
Bitewings - two radiographic images |
34 |
33 |
$330.00 |