| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
257 |
75 |
$6K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
255 |
165 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
84 |
84 |
$1K |
| D2160 |
|
86 |
61 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
104 |
99 |
$735.00 |
| D1120 |
Prophylaxis - child |
93 |
93 |
$520.00 |
| D0274 |
Bitewings - four radiographic images |
57 |
57 |
$406.00 |
| D0210 |
Intraoral - complete series of radiographic images |
23 |
23 |
$348.00 |
| D0220 |
Intraoral - periapical first radiographic image |
109 |
95 |
$299.00 |
| D1206 |
Topical application of fluoride varnish |
94 |
94 |
$266.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
32 |
31 |
$182.00 |
| D2140 |
|
18 |
17 |
$156.00 |
| D0120 |
Periodic oral evaluation - established patient |
82 |
82 |
$140.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
29 |
13 |
$54.00 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$52.00 |
| D1354 |
|
244 |
138 |
$4.00 |
| D1330 |
|
118 |
118 |
$0.00 |