| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
402 |
402 |
$27K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
37 |
30 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
367 |
367 |
$16K |
| D3221 |
|
234 |
184 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
144 |
85 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
56 |
37 |
$4K |
| D1110 |
Prophylaxis - adult |
47 |
47 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
58 |
24 |
$3K |
| D1206 |
Topical application of fluoride varnish |
187 |
186 |
$3K |
| D0350 |
|
194 |
87 |
$2K |
| D1120 |
Prophylaxis - child |
28 |
28 |
$750.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
165 |
38 |
$656.10 |