| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
36 |
26 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
953 |
820 |
$12K |
| D1120 |
Prophylaxis - child |
646 |
557 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,027 |
883 |
$11K |
| D1110 |
Prophylaxis - adult |
356 |
311 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
129 |
73 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
178 |
75 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
475 |
392 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
431 |
341 |
$3K |
| D0272 |
Bitewings - two radiographic images |
219 |
190 |
$3K |
| D0274 |
Bitewings - four radiographic images |
110 |
89 |
$2K |
| D1351 |
Sealant - per tooth |
112 |
24 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$264.00 |