| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9420 |
|
759 |
705 |
$165K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,619 |
455 |
$70K |
| D2140 |
|
1,129 |
308 |
$36K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
398 |
193 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
739 |
659 |
$14K |
| D1110 |
Prophylaxis - adult |
628 |
567 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,729 |
471 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
900 |
774 |
$6K |
| D1999 |
|
141 |
126 |
$2K |
| D2330 |
|
52 |
13 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
192 |
178 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
147 |
141 |
$2K |
| D0272 |
Bitewings - two radiographic images |
126 |
103 |
$2K |
| D1120 |
Prophylaxis - child |
82 |
78 |
$1K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
15 |
15 |
$981.40 |