| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
1,500 |
681 |
$33K |
| D0140 |
Limited oral evaluation - problem focused |
2,180 |
2,134 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,809 |
2,137 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
2,095 |
2,085 |
$24K |
| D1110 |
Prophylaxis - adult |
787 |
778 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
2,615 |
2,566 |
$7K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
116 |
86 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
72 |
38 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
95 |
94 |
$2K |
| D2140 |
|
71 |
41 |
$2K |
| D1120 |
Prophylaxis - child |
28 |
28 |
$448.00 |
| D1206 |
Topical application of fluoride varnish |
15 |
15 |
$165.50 |