| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,261 |
2,230 |
$99K |
| D0120 |
Periodic oral evaluation - established patient |
2,117 |
2,087 |
$54K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,200 |
1,192 |
$30K |
| D0272 |
Bitewings - two radiographic images |
1,946 |
1,921 |
$19K |
| D7140 |
Extraction, erupted tooth or exposed root |
309 |
137 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
2,611 |
2,502 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,683 |
1,761 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
77 |
73 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
67 |
53 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
17 |
15 |
$998.75 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$680.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
13 |
12 |
$675.00 |
| D0170 |
|
14 |
14 |
$516.85 |
| D2140 |
|
13 |
12 |
$450.00 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$311.25 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$202.66 |
| D1999 |
|
239 |
210 |
$0.00 |