| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
786 |
690 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
606 |
533 |
$7K |
| D0272 |
Bitewings - two radiographic images |
408 |
364 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
111 |
90 |
$1K |
| D0330 |
Panoramic radiographic image |
34 |
34 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
80 |
80 |
$1K |
| D1999 |
|
168 |
145 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
205 |
187 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
163 |
73 |
$820.90 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
14 |
12 |
$507.50 |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
16 |
12 |
$411.47 |
| D2140 |
|
17 |
13 |
$367.20 |