| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2752 |
|
263 |
228 |
$109K |
| D2750 |
|
241 |
203 |
$91K |
| D1110 |
Prophylaxis - adult |
1,407 |
1,407 |
$53K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
201 |
197 |
$52K |
| D2954 |
|
503 |
451 |
$49K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
491 |
353 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
1,221 |
1,221 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
2,178 |
2,149 |
$20K |
| D0274 |
Bitewings - four radiographic images |
1,006 |
1,006 |
$20K |
| D9110 |
|
558 |
551 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
209 |
159 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,275 |
1,275 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
142 |
142 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
203 |
201 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
92 |
92 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$127.20 |