| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
3,654 |
2,058 |
$314K |
| D1120 |
Prophylaxis - child |
5,286 |
5,286 |
$182K |
| D0120 |
Periodic oral evaluation - established patient |
7,778 |
7,778 |
$179K |
| D1110 |
Prophylaxis - adult |
3,823 |
3,823 |
$177K |
| D1206 |
Topical application of fluoride varnish |
8,827 |
8,827 |
$144K |
| D0140 |
Limited oral evaluation - problem focused |
4,050 |
4,036 |
$142K |
| D0330 |
Panoramic radiographic image |
2,714 |
2,713 |
$110K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,212 |
2,212 |
$91K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
2,623 |
2,566 |
$85K |
| D0272 |
Bitewings - two radiographic images |
3,687 |
3,687 |
$69K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
89 |
89 |
$49K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
616 |
431 |
$46K |
| D0220 |
Intraoral - periapical first radiographic image |
3,439 |
3,426 |
$44K |
| D1351 |
Sealant - per tooth |
1,058 |
360 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
303 |
236 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,842 |
1,208 |
$27K |
| D9248 |
|
295 |
294 |
$20K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
138 |
88 |
$18K |
| D0240 |
|
1,173 |
928 |
$18K |
| D0145 |
Oral evaluation for a patient under three years of age |
416 |
416 |
$15K |
| D9222 |
|
60 |
60 |
$6K |
| D0274 |
Bitewings - four radiographic images |
192 |
192 |
$5K |
| D9920 |
|
41 |
41 |
$2K |
| D1354 |
|
93 |
39 |
$651.00 |