| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,658 |
1,034 |
$281K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
308 |
293 |
$130K |
| D2950 |
|
920 |
777 |
$92K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,137 |
518 |
$91K |
| D1110 |
Prophylaxis - adult |
2,196 |
2,137 |
$83K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
575 |
270 |
$75K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,297 |
1,230 |
$56K |
| D0140 |
Limited oral evaluation - problem focused |
1,335 |
1,291 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
1,798 |
1,732 |
$44K |
| D0274 |
Bitewings - four radiographic images |
1,404 |
1,357 |
$42K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,985 |
1,912 |
$33K |
| D0220 |
Intraoral - periapical first radiographic image |
1,430 |
1,377 |
$22K |
| D1120 |
Prophylaxis - child |
556 |
536 |
$15K |
| D0330 |
Panoramic radiographic image |
156 |
146 |
$8K |
| D0272 |
Bitewings - two radiographic images |
31 |
27 |
$534.09 |