| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
2,056 |
948 |
$117K |
| D1120 |
Prophylaxis - child |
2,411 |
2,360 |
$46K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
792 |
568 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
2,488 |
2,432 |
$41K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,756 |
2,689 |
$40K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
657 |
464 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
817 |
794 |
$21K |
| D1351 |
Sealant - per tooth |
955 |
447 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
731 |
710 |
$16K |
| D0272 |
Bitewings - two radiographic images |
1,593 |
1,560 |
$16K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
151 |
78 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,932 |
1,870 |
$10K |
| D1110 |
Prophylaxis - adult |
255 |
255 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,876 |
805 |
$8K |
| D0274 |
Bitewings - four radiographic images |
267 |
258 |
$5K |
| D0240 |
|
437 |
228 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
35 |
26 |
$2K |
| D0330 |
Panoramic radiographic image |
42 |
42 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
24 |
24 |
$25.00 |