| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,478 |
1,473 |
$27K |
| D1120 |
Prophylaxis - child |
1,012 |
1,005 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,262 |
1,260 |
$20K |
| D1110 |
Prophylaxis - adult |
342 |
341 |
$14K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
153 |
101 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
101 |
57 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
69 |
36 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
120 |
119 |
$3K |
| D0272 |
Bitewings - two radiographic images |
269 |
268 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
68 |
68 |
$3K |
| D0274 |
Bitewings - four radiographic images |
60 |
60 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
262 |
255 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
241 |
156 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
18 |
12 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
13 |
$2K |
| D2140 |
|
15 |
12 |
$600.00 |