| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
1,445 |
274 |
$58K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,222 |
282 |
$53K |
| D9420 |
|
505 |
470 |
$26K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
157 |
14 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
223 |
84 |
$12K |
| D9243 |
|
43 |
31 |
$12K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
107 |
29 |
$11K |
| D2330 |
|
204 |
70 |
$9K |
| D9239 |
|
36 |
33 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
484 |
454 |
$4K |
| D0272 |
Bitewings - two radiographic images |
220 |
202 |
$3K |
| D1120 |
Prophylaxis - child |
38 |
38 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
79 |
73 |
$767.80 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$737.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
98 |
34 |
$670.86 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
19 |
19 |
$487.50 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$225.00 |