| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
952 |
671 |
$20K |
| D2140 |
|
879 |
195 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
599 |
438 |
$9K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
301 |
89 |
$8K |
| D0272 |
Bitewings - two radiographic images |
569 |
367 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,448 |
555 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
508 |
329 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
275 |
186 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
581 |
426 |
$3K |
| D2330 |
|
75 |
13 |
$2K |
| D1120 |
Prophylaxis - child |
76 |
55 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
66 |
55 |
$727.77 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
14 |
13 |
$489.40 |