| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2931 |
|
356 |
223 |
$41K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
103 |
82 |
$39K |
| D2954 |
|
226 |
121 |
$31K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
259 |
139 |
$17K |
| D3320 |
|
50 |
33 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
615 |
609 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
231 |
60 |
$13K |
| D2394 |
|
148 |
68 |
$11K |
| D3310 |
|
36 |
13 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
458 |
452 |
$7K |
| D1110 |
Prophylaxis - adult |
221 |
219 |
$7K |
| D0274 |
Bitewings - four radiographic images |
362 |
360 |
$7K |
| D0330 |
Panoramic radiographic image |
170 |
170 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
124 |
66 |
$6K |
| D1206 |
Topical application of fluoride varnish |
406 |
400 |
$6K |
| D2160 |
|
73 |
43 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
94 |
92 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
740 |
727 |
$4K |
| D1120 |
Prophylaxis - child |
166 |
161 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
56 |
36 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
112 |
111 |
$3K |
| D2161 |
|
33 |
17 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
466 |
267 |
$2K |
| D2140 |
|
43 |
28 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
38 |
15 |
$2K |
| D0272 |
Bitewings - two radiographic images |
15 |
14 |
$140.00 |