| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2750 |
|
205 |
132 |
$101K |
| D1110 |
Prophylaxis - adult |
1,031 |
1,028 |
$68K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
373 |
217 |
$51K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
448 |
195 |
$48K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
787 |
784 |
$44K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
229 |
120 |
$26K |
| D0210 |
Intraoral - complete series of radiographic images |
406 |
404 |
$23K |
| D1206 |
Topical application of fluoride varnish |
871 |
871 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
489 |
489 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
288 |
286 |
$14K |
| D0330 |
Panoramic radiographic image |
235 |
232 |
$11K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
14 |
13 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
728 |
669 |
$8K |
| D3120 |
|
224 |
115 |
$8K |
| D2950 |
|
58 |
44 |
$5K |
| D1351 |
Sealant - per tooth |
104 |
14 |
$4K |
| D4341 |
|
38 |
13 |
$3K |
| D0274 |
Bitewings - four radiographic images |
117 |
117 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
89 |
86 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
211 |
208 |
$2K |
| D1120 |
Prophylaxis - child |
14 |
14 |
$684.60 |