| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,317 |
1,275 |
$51K |
| D2752 |
|
88 |
55 |
$38K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,549 |
1,497 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
362 |
194 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
1,118 |
1,093 |
$25K |
| D0210 |
Intraoral - complete series of radiographic images |
389 |
373 |
$22K |
| D0274 |
Bitewings - four radiographic images |
813 |
788 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
556 |
534 |
$14K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
16 |
12 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
278 |
264 |
$3K |
| D1120 |
Prophylaxis - child |
94 |
94 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
39 |
27 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
24 |
12 |
$2K |
| D0330 |
Panoramic radiographic image |
18 |
18 |
$595.49 |
| D1999 |
|
71 |
65 |
$0.00 |