| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,454 |
1,420 |
$60K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
645 |
359 |
$57K |
| D0274 |
Bitewings - four radiographic images |
1,442 |
1,404 |
$34K |
| D0330 |
Panoramic radiographic image |
760 |
649 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,071 |
840 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
1,329 |
1,309 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
982 |
971 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
239 |
129 |
$18K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
218 |
121 |
$18K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
114 |
80 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,477 |
923 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,670 |
1,484 |
$13K |
| D1120 |
Prophylaxis - child |
350 |
350 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
594 |
498 |
$10K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
57 |
54 |
$10K |
| D2950 |
|
42 |
37 |
$6K |
| D4346 |
|
14 |
14 |
$786.20 |