| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2750 |
|
642 |
256 |
$262K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,523 |
784 |
$124K |
| D1110 |
Prophylaxis - adult |
2,404 |
2,404 |
$96K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,210 |
588 |
$73K |
| D2954 |
|
621 |
268 |
$72K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
321 |
262 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,671 |
1,671 |
$37K |
| D0210 |
Intraoral - complete series of radiographic images |
827 |
825 |
$32K |
| D0274 |
Bitewings - four radiographic images |
812 |
812 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
652 |
652 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,640 |
1,634 |
$15K |
| D3320 |
|
51 |
27 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,224 |
1,224 |
$9K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
17 |
14 |
$5K |
| D2394 |
|
19 |
15 |
$4K |
| D2330 |
|
77 |
43 |
$3K |
| D1120 |
Prophylaxis - child |
12 |
12 |
$514.24 |