| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
58 |
36 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
54 |
38 |
$4K |
| D2140 |
|
62 |
50 |
$4K |
| D1120 |
Prophylaxis - child |
95 |
95 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
47 |
46 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
100 |
100 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
62 |
61 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
78 |
78 |
$2K |
| D1110 |
Prophylaxis - adult |
42 |
42 |
$2K |
| D0274 |
Bitewings - four radiographic images |
43 |
43 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
54 |
52 |
$832.20 |