| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
975 |
967 |
$53K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
38 |
36 |
$28K |
| D0274 |
Bitewings - four radiographic images |
330 |
329 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
280 |
270 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
407 |
404 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
294 |
279 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
53 |
53 |
$2K |
| D2950 |
|
14 |
12 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
26 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
26 |
25 |
$749.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
53 |
53 |
$700.00 |