| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
179 |
178 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
137 |
137 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
186 |
186 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
70 |
37 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
785 |
162 |
$3K |
| D4341 |
|
43 |
12 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
37 |
26 |
$2K |
| D1206 |
Topical application of fluoride varnish |
82 |
82 |
$1K |
| D0272 |
Bitewings - two radiographic images |
64 |
64 |
$716.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$360.00 |