| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
873 |
205 |
$58K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
647 |
316 |
$49K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
449 |
210 |
$45K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
502 |
214 |
$32K |
| D0210 |
Intraoral - complete series of radiographic images |
620 |
592 |
$31K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
62 |
41 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
971 |
952 |
$28K |
| D1110 |
Prophylaxis - adult |
712 |
688 |
$24K |
| D2394 |
|
141 |
70 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
883 |
876 |
$16K |
| D1120 |
Prophylaxis - child |
432 |
425 |
$9K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
153 |
40 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
506 |
497 |
$7K |
| D0274 |
Bitewings - four radiographic images |
165 |
165 |
$4K |
| D2332 |
|
25 |
13 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
379 |
362 |
$2K |
| D1206 |
Topical application of fluoride varnish |
81 |
76 |
$1K |
| D0330 |
Panoramic radiographic image |
28 |
24 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
144 |
68 |
$651.00 |
| D0350 |
|
92 |
92 |
$393.92 |