| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
3,070 |
721 |
$205K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,265 |
264 |
$130K |
| D0120 |
Periodic oral evaluation - established patient |
3,855 |
3,821 |
$76K |
| D1110 |
Prophylaxis - adult |
1,932 |
1,909 |
$68K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,098 |
546 |
$65K |
| D1120 |
Prophylaxis - child |
1,985 |
1,968 |
$61K |
| D1351 |
Sealant - per tooth |
2,187 |
608 |
$55K |
| D1206 |
Topical application of fluoride varnish |
2,826 |
2,805 |
$52K |
| D0274 |
Bitewings - four radiographic images |
1,186 |
1,172 |
$33K |
| D7240 |
Removal of impacted tooth - completely bony |
138 |
53 |
$29K |
| D5110 |
|
48 |
48 |
$25K |
| D0330 |
Panoramic radiographic image |
714 |
705 |
$24K |
| D5120 |
|
38 |
38 |
$20K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
314 |
193 |
$19K |
| D0272 |
Bitewings - two radiographic images |
1,067 |
1,056 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
340 |
193 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
792 |
785 |
$16K |
| D2390 |
|
111 |
39 |
$16K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
159 |
67 |
$12K |
| D9110 |
|
284 |
279 |
$9K |
| D1510 |
|
66 |
39 |
$8K |
| D2335 |
|
105 |
58 |
$7K |
| D7230 |
|
34 |
12 |
$6K |
| D2332 |
|
100 |
64 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
744 |
731 |
$6K |
| D2331 |
|
101 |
62 |
$5K |
| D2330 |
|
72 |
41 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
272 |
157 |
$3K |
| D2394 |
|
42 |
31 |
$2K |
| D7310 |
|
40 |
13 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
99 |
99 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
27 |
24 |
$1K |
| D1999 |
|
40 |
40 |
$273.00 |