| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
246 |
104 |
$14K |
| D1110 |
Prophylaxis - adult |
423 |
421 |
$14K |
| D0330 |
Panoramic radiographic image |
310 |
308 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
490 |
486 |
$9K |
| D9110 |
|
253 |
246 |
$7K |
| D0272 |
Bitewings - two radiographic images |
325 |
325 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
549 |
523 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
416 |
384 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
46 |
46 |
$842.40 |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
15 |
12 |
$770.00 |
| D2140 |
|
20 |
13 |
$720.00 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$390.00 |