| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,451 |
1,451 |
$77K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
929 |
513 |
$72K |
| D0330 |
Panoramic radiographic image |
941 |
941 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
982 |
982 |
$28K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
498 |
303 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
843 |
843 |
$23K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
191 |
123 |
$20K |
| D0274 |
Bitewings - four radiographic images |
863 |
863 |
$10K |
| D1206 |
Topical application of fluoride varnish |
880 |
880 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
816 |
788 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
116 |
40 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
314 |
305 |
$6K |
| D1120 |
Prophylaxis - child |
147 |
147 |
$6K |
| D9310 |
|
30 |
30 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
18 |
13 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
216 |
151 |
$824.60 |