| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
2,829 |
1,457 |
$247K |
| D2332 |
|
1,230 |
683 |
$114K |
| D2750 |
|
267 |
110 |
$96K |
| D1110 |
Prophylaxis - adult |
2,156 |
2,150 |
$81K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
897 |
636 |
$60K |
| D0120 |
Periodic oral evaluation - established patient |
2,332 |
2,328 |
$47K |
| D0330 |
Panoramic radiographic image |
788 |
785 |
$21K |
| D2954 |
|
162 |
66 |
$14K |
| D0274 |
Bitewings - four radiographic images |
243 |
243 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
370 |
366 |
$4K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
13 |
13 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
158 |
157 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
269 |
269 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
31 |
31 |
$656.18 |
| D1120 |
Prophylaxis - child |
14 |
14 |
$407.89 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$142.32 |