| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
530 |
308 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
1,220 |
959 |
$21K |
| D1110 |
Prophylaxis - adult |
598 |
487 |
$20K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
393 |
207 |
$20K |
| D0330 |
Panoramic radiographic image |
277 |
221 |
$12K |
| D2140 |
|
274 |
131 |
$11K |
| D1120 |
Prophylaxis - child |
546 |
415 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
633 |
479 |
$10K |
| D0274 |
Bitewings - four radiographic images |
256 |
213 |
$5K |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$147.00 |