| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
701 |
127 |
$54K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
267 |
98 |
$22K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
41 |
25 |
$22K |
| D2950 |
|
169 |
103 |
$21K |
| D2931 |
|
106 |
73 |
$18K |
| D1110 |
Prophylaxis - adult |
276 |
275 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
252 |
252 |
$11K |
| D3320 |
|
23 |
13 |
$10K |
| D2330 |
|
96 |
25 |
$9K |
| D1206 |
Topical application of fluoride varnish |
348 |
346 |
$8K |
| D0274 |
Bitewings - four radiographic images |
247 |
247 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
60 |
60 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
236 |
236 |
$6K |
| D1120 |
Prophylaxis - child |
148 |
148 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
81 |
79 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
14 |
$2K |
| D0330 |
Panoramic radiographic image |
17 |
17 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
33 |
33 |
$265.41 |