| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,464 |
1,456 |
$48K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
429 |
274 |
$31K |
| D0274 |
Bitewings - four radiographic images |
1,145 |
1,139 |
$31K |
| D7140 |
Extraction, erupted tooth or exposed root |
457 |
188 |
$27K |
| D0330 |
Panoramic radiographic image |
776 |
768 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
1,192 |
1,186 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,018 |
1,011 |
$19K |
| D9110 |
|
634 |
628 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
362 |
153 |
$17K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
130 |
93 |
$14K |
| D8670 |
Periodic orthodontic treatment visit |
118 |
118 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,368 |
1,325 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
376 |
318 |
$8K |
| D2332 |
|
49 |
46 |
$7K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
14 |
12 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
824 |
813 |
$6K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
15 |
14 |
$5K |
| D9920 |
|
15 |
15 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
74 |
74 |
$1K |
| D0601 |
|
91 |
91 |
$910.00 |
| D1330 |
|
126 |
126 |
$693.02 |
| D1310 |
|
121 |
121 |
$661.40 |
| D1120 |
Prophylaxis - child |
25 |
25 |
$467.25 |