| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
32 |
21 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
34 |
17 |
$2K |
| D2140 |
|
36 |
23 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
53 |
53 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
64 |
64 |
$2K |
| D1120 |
Prophylaxis - child |
54 |
54 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
124 |
117 |
$1K |
| D0274 |
Bitewings - four radiographic images |
44 |
44 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
65 |
65 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
109 |
105 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
36 |
36 |
$1K |
| D7971 |
|
18 |
12 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
29 |
29 |
$677.44 |
| D1110 |
Prophylaxis - adult |
15 |
15 |
$654.10 |
| D0272 |
Bitewings - two radiographic images |
24 |
24 |
$504.72 |