| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
924 |
501 |
$127K |
| D1120 |
Prophylaxis - child |
3,600 |
3,600 |
$124K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
742 |
370 |
$100K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,507 |
1,507 |
$62K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
570 |
240 |
$60K |
| D1206 |
Topical application of fluoride varnish |
3,449 |
3,449 |
$56K |
| D0120 |
Periodic oral evaluation - established patient |
2,361 |
2,361 |
$56K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
488 |
260 |
$53K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,110 |
2,914 |
$44K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,367 |
1,305 |
$44K |
| D0220 |
Intraoral - periapical first radiographic image |
3,148 |
3,128 |
$40K |
| D0272 |
Bitewings - two radiographic images |
1,865 |
1,865 |
$35K |
| D0140 |
Limited oral evaluation - problem focused |
649 |
643 |
$25K |
| D1110 |
Prophylaxis - adult |
501 |
501 |
$23K |
| D1351 |
Sealant - per tooth |
786 |
215 |
$23K |
| D0330 |
Panoramic radiographic image |
426 |
426 |
$21K |
| D0145 |
Oral evaluation for a patient under three years of age |
204 |
204 |
$13K |
| D0274 |
Bitewings - four radiographic images |
202 |
202 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
17 |
12 |
$1K |