| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
796 |
796 |
$52K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
283 |
172 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
742 |
742 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
127 |
84 |
$14K |
| D2780 |
|
14 |
12 |
$11K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
14 |
13 |
$10K |
| D0274 |
Bitewings - four radiographic images |
159 |
159 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
63 |
63 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
42 |
42 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
143 |
141 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
42 |
42 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
17 |
17 |
$910.35 |