| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
2,779 |
543 |
$172K |
| D1110 |
Prophylaxis - adult |
485 |
485 |
$17K |
| D0330 |
Panoramic radiographic image |
374 |
369 |
$14K |
| D0274 |
Bitewings - four radiographic images |
325 |
325 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
143 |
73 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
425 |
424 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
74 |
26 |
$8K |
| D1351 |
Sealant - per tooth |
286 |
44 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
347 |
343 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
121 |
55 |
$6K |
| D1330 |
|
509 |
509 |
$6K |
| D1310 |
|
511 |
511 |
$6K |
| D1206 |
Topical application of fluoride varnish |
302 |
299 |
$5K |
| D1120 |
Prophylaxis - child |
172 |
171 |
$5K |
| D7310 |
|
65 |
27 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
18 |
17 |
$792.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
37 |
37 |
$674.64 |
| D0220 |
Intraoral - periapical first radiographic image |
93 |
93 |
$546.15 |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$240.00 |