| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2750 |
|
271 |
150 |
$127K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
505 |
236 |
$86K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
51 |
47 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
276 |
145 |
$38K |
| D4341 |
|
295 |
93 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
374 |
369 |
$21K |
| D2950 |
|
201 |
121 |
$17K |
| D2394 |
|
95 |
60 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
146 |
70 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
320 |
275 |
$15K |
| D1110 |
Prophylaxis - adult |
184 |
184 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
186 |
185 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
891 |
671 |
$10K |
| D1206 |
Topical application of fluoride varnish |
354 |
352 |
$9K |
| D3120 |
|
192 |
53 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
299 |
263 |
$4K |
| D0330 |
Panoramic radiographic image |
64 |
64 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
90 |
90 |
$3K |
| D0274 |
Bitewings - four radiographic images |
94 |
94 |
$2K |
| D4910 |
|
12 |
12 |
$648.00 |