| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1354 |
|
7,069 |
411 |
$87K |
| D2335 |
|
3,124 |
727 |
$52K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
260 |
250 |
$26K |
| D2740 |
Crown - porcelain/ceramic |
397 |
374 |
$10K |
| D1110 |
Prophylaxis - adult |
564 |
560 |
$9K |
| D2950 |
|
677 |
613 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
574 |
569 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,685 |
314 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,097 |
1,146 |
$7K |
| D0274 |
Bitewings - four radiographic images |
576 |
570 |
$5K |
| D2750 |
|
153 |
138 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
1,253 |
1,214 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
569 |
564 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
345 |
338 |
$2K |
| D3320 |
|
144 |
128 |
$1K |
| D1352 |
|
1,192 |
203 |
$567.34 |
| D2332 |
|
42 |
27 |
$170.52 |
| D5621 |
|
44 |
44 |
$0.00 |
| D2161 |
|
130 |
16 |
$0.00 |
| D5622 |
|
44 |
44 |
$0.00 |