| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9310 |
|
1,951 |
1,950 |
$84K |
| D0330 |
Panoramic radiographic image |
1,589 |
1,589 |
$46K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
814 |
288 |
$41K |
| D0220 |
Intraoral - periapical first radiographic image |
3,335 |
3,311 |
$31K |
| D1120 |
Prophylaxis - child |
927 |
926 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
1,061 |
1,060 |
$22K |
| D1206 |
Topical application of fluoride varnish |
709 |
709 |
$17K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
20 |
18 |
$12K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
138 |
93 |
$12K |
| D4341 |
|
299 |
79 |
$11K |
| D9243 |
|
118 |
103 |
$10K |
| D0274 |
Bitewings - four radiographic images |
394 |
394 |
$8K |
| D1351 |
Sealant - per tooth |
212 |
70 |
$8K |
| D9239 |
|
110 |
105 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,191 |
1,186 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
146 |
87 |
$5K |
| D0272 |
Bitewings - two radiographic images |
287 |
284 |
$4K |
| D0160 |
|
122 |
122 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
197 |
197 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
46 |
39 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
59 |
59 |
$1K |
| D0340 |
|
24 |
24 |
$780.79 |
| D9110 |
|
40 |
40 |
$666.32 |
| D1110 |
Prophylaxis - adult |
15 |
15 |
$602.98 |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
27 |
$207.63 |