| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
341 |
341 |
$21K |
| D1110 |
Prophylaxis - adult |
261 |
261 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
230 |
96 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
235 |
235 |
$11K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
12 |
12 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
119 |
119 |
$5K |
| D0350 |
|
441 |
171 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
38 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
478 |
139 |
$2K |
| D0274 |
Bitewings - four radiographic images |
85 |
85 |
$2K |
| D0330 |
Panoramic radiographic image |
55 |
55 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$1K |