| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2750 |
|
89 |
58 |
$44K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
145 |
95 |
$25K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
30 |
26 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
159 |
90 |
$22K |
| D1110 |
Prophylaxis - adult |
289 |
289 |
$19K |
| D1351 |
Sealant - per tooth |
324 |
55 |
$13K |
| D1206 |
Topical application of fluoride varnish |
429 |
429 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
349 |
349 |
$11K |
| D1120 |
Prophylaxis - child |
205 |
205 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
133 |
133 |
$7K |
| D2950 |
|
87 |
56 |
$7K |
| D0330 |
Panoramic radiographic image |
145 |
145 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
132 |
131 |
$6K |
| D0274 |
Bitewings - four radiographic images |
224 |
224 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
204 |
203 |
$2K |
| D1330 |
|
167 |
167 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
23 |
23 |
$150.88 |