| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
1,639 |
714 |
$212K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,113 |
526 |
$204K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,462 |
694 |
$189K |
| D1120 |
Prophylaxis - child |
2,866 |
2,746 |
$171K |
| D0120 |
Periodic oral evaluation - established patient |
2,412 |
2,305 |
$108K |
| D1206 |
Topical application of fluoride varnish |
2,928 |
2,702 |
$77K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,359 |
1,213 |
$70K |
| D1351 |
Sealant - per tooth |
1,369 |
480 |
$64K |
| D9248 |
|
276 |
252 |
$47K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
232 |
165 |
$37K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,780 |
678 |
$36K |
| D0220 |
Intraoral - periapical first radiographic image |
958 |
820 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
220 |
210 |
$13K |
| D0145 |
Oral evaluation for a patient under three years of age |
239 |
234 |
$13K |
| D2330 |
|
79 |
49 |
$9K |
| D0272 |
Bitewings - two radiographic images |
213 |
206 |
$8K |
| D0240 |
|
62 |
61 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
23 |
23 |
$619.04 |
| D1354 |
|
435 |
375 |
$0.00 |