| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
352 |
71 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
204 |
112 |
$21K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
130 |
72 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
157 |
85 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
89 |
89 |
$10K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
13 |
12 |
$9K |
| D2331 |
|
69 |
30 |
$8K |
| D1110 |
Prophylaxis - adult |
107 |
107 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
135 |
135 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
161 |
161 |
$5K |
| D0274 |
Bitewings - four radiographic images |
126 |
126 |
$4K |
| D0330 |
Panoramic radiographic image |
50 |
50 |
$4K |
| D2330 |
|
41 |
29 |
$4K |
| D2335 |
|
19 |
14 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
71 |
71 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
94 |
49 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
91 |
91 |
$874.87 |
| D1120 |
Prophylaxis - child |
15 |
15 |
$573.30 |