| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
454 |
191 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
131 |
130 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
247 |
245 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
113 |
111 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
86 |
71 |
$782.40 |
| D0220 |
Intraoral - periapical first radiographic image |
148 |
147 |
$676.58 |
| D1999 |
|
33 |
27 |
$231.00 |
| D2140 |
|
36 |
31 |
$208.00 |
| D2160 |
|
13 |
13 |
$158.00 |