| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
2,295 |
700 |
$131K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,227 |
317 |
$130K |
| D0330 |
Panoramic radiographic image |
2,524 |
2,263 |
$124K |
| D1120 |
Prophylaxis - child |
5,579 |
5,025 |
$118K |
| D0120 |
Periodic oral evaluation - established patient |
5,904 |
5,370 |
$105K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,295 |
2,934 |
$90K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,232 |
615 |
$71K |
| D1206 |
Topical application of fluoride varnish |
4,035 |
3,918 |
$64K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,041 |
438 |
$56K |
| D1110 |
Prophylaxis - adult |
1,342 |
1,261 |
$48K |
| D0272 |
Bitewings - two radiographic images |
3,355 |
3,029 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,700 |
1,260 |
$27K |
| D0274 |
Bitewings - four radiographic images |
962 |
923 |
$20K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
307 |
170 |
$17K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
245 |
94 |
$16K |
| D2140 |
|
227 |
124 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
309 |
299 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
98 |
66 |
$7K |
| D0240 |
|
483 |
223 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
82 |
25 |
$5K |
| D2160 |
|
54 |
41 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
685 |
666 |
$3K |
| D1351 |
Sealant - per tooth |
97 |
26 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
27 |
$2K |
| D2331 |
|
17 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
184 |
61 |
$929.25 |