| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
626 |
258 |
$34K |
| D0330 |
Panoramic radiographic image |
736 |
734 |
$32K |
| D1110 |
Prophylaxis - adult |
582 |
581 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
728 |
726 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
319 |
191 |
$16K |
| D2394 |
|
186 |
128 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
188 |
139 |
$11K |
| D0274 |
Bitewings - four radiographic images |
582 |
581 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
660 |
660 |
$10K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
15 |
14 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
875 |
859 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
76 |
45 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
226 |
226 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
586 |
555 |
$3K |
| D1120 |
Prophylaxis - child |
128 |
128 |
$3K |
| D2335 |
|
21 |
13 |
$2K |
| D2332 |
|
18 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
58 |
57 |
$1K |
| D2331 |
|
18 |
13 |
$1K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$120.00 |