| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2750 |
|
431 |
213 |
$212K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
129 |
111 |
$96K |
| D1110 |
Prophylaxis - adult |
497 |
497 |
$33K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
230 |
148 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
508 |
508 |
$29K |
| D2950 |
|
279 |
155 |
$24K |
| D3320 |
|
22 |
15 |
$14K |
| D0330 |
Panoramic radiographic image |
274 |
274 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
392 |
392 |
$12K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
102 |
40 |
$11K |
| D0274 |
Bitewings - four radiographic images |
365 |
365 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
72 |
52 |
$8K |
| D1206 |
Topical application of fluoride varnish |
223 |
223 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
476 |
472 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
106 |
104 |
$5K |
| D4341 |
|
47 |
15 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
59 |
59 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
231 |
230 |
$3K |
| D1120 |
Prophylaxis - child |
27 |
27 |
$1K |