| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2332 |
|
2,239 |
775 |
$145K |
| D1110 |
Prophylaxis - adult |
1,239 |
1,239 |
$48K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
112 |
55 |
$40K |
| D2331 |
|
495 |
138 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
790 |
372 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
472 |
252 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
775 |
775 |
$15K |
| D0274 |
Bitewings - four radiographic images |
730 |
730 |
$14K |
| D2954 |
|
137 |
73 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
267 |
267 |
$11K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
29 |
15 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
743 |
737 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
285 |
285 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
903 |
893 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$131.20 |