| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,675 |
2,675 |
$143K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,633 |
810 |
$136K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,416 |
577 |
$121K |
| D0120 |
Periodic oral evaluation - established patient |
3,256 |
3,256 |
$91K |
| D1120 |
Prophylaxis - child |
1,238 |
1,238 |
$49K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
874 |
873 |
$38K |
| D0210 |
Intraoral - complete series of radiographic images |
435 |
435 |
$32K |
| D2160 |
|
211 |
128 |
$22K |
| D2140 |
|
313 |
183 |
$22K |
| D0274 |
Bitewings - four radiographic images |
590 |
590 |
$21K |
| D1206 |
Topical application of fluoride varnish |
713 |
713 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
70 |
69 |
$3K |
| D0272 |
Bitewings - two radiographic images |
91 |
91 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
43 |
43 |
$746.75 |