| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
521 |
520 |
$33K |
| D0210 |
Intraoral - complete series of radiographic images |
472 |
470 |
$22K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
42 |
38 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
280 |
140 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
305 |
301 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,227 |
509 |
$10K |
| D1120 |
Prophylaxis - child |
250 |
246 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
117 |
64 |
$6K |
| D0274 |
Bitewings - four radiographic images |
349 |
349 |
$6K |
| D1206 |
Topical application of fluoride varnish |
482 |
480 |
$5K |
| D1110 |
Prophylaxis - adult |
53 |
53 |
$5K |
| D9430 |
|
114 |
113 |
$4K |
| D0350 |
|
408 |
163 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
17 |
17 |
$116.00 |