| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
514 |
514 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
762 |
761 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
227 |
134 |
$12K |
| D2954 |
|
102 |
80 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
474 |
471 |
$10K |
| D0330 |
Panoramic radiographic image |
286 |
285 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
174 |
50 |
$10K |
| D1206 |
Topical application of fluoride varnish |
599 |
599 |
$9K |
| D1120 |
Prophylaxis - child |
385 |
385 |
$7K |
| D0274 |
Bitewings - four radiographic images |
420 |
420 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
145 |
136 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
258 |
258 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
67 |
47 |
$4K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
12 |
12 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
667 |
655 |
$4K |
| D2931 |
|
27 |
26 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
352 |
245 |
$2K |
| D0272 |
Bitewings - two radiographic images |
166 |
166 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
12 |
$1K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
17 |
12 |
$923.04 |
| D1208 |
Topical application of fluoride, excluding varnish |
25 |
25 |
$272.50 |