| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
330 |
76 |
$23K |
| D1110 |
Prophylaxis - adult |
295 |
247 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
365 |
310 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
287 |
232 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
387 |
284 |
$7K |
| D0272 |
Bitewings - two radiographic images |
276 |
205 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
303 |
211 |
$4K |
| D0330 |
Panoramic radiographic image |
44 |
44 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
34 |
16 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
22 |
15 |
$438.90 |