| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2950 |
|
151 |
116 |
$23K |
| D1351 |
Sealant - per tooth |
583 |
56 |
$17K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
31 |
25 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
308 |
308 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
248 |
243 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
65 |
37 |
$8K |
| D1110 |
Prophylaxis - adult |
136 |
136 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
406 |
394 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
41 |
25 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
62 |
62 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
305 |
187 |
$3K |
| D1206 |
Topical application of fluoride varnish |
36 |
36 |
$812.55 |
| D1120 |
Prophylaxis - child |
16 |
16 |
$710.90 |
| D0120 |
Periodic oral evaluation - established patient |
12 |
12 |
$366.30 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$316.38 |