| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
312 |
150 |
$23K |
| D1110 |
Prophylaxis - adult |
543 |
542 |
$21K |
| D0274 |
Bitewings - four radiographic images |
487 |
486 |
$14K |
| D0330 |
Panoramic radiographic image |
270 |
270 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
389 |
388 |
$8K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
129 |
90 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
325 |
324 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
157 |
157 |
$3K |
| D1120 |
Prophylaxis - child |
83 |
83 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
183 |
181 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
24 |
24 |
$1K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$190.40 |