| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
799 |
728 |
$29K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
25 |
24 |
$17K |
| D1110 |
Prophylaxis - adult |
448 |
389 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
606 |
531 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
648 |
571 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
249 |
205 |
$4K |
| D2940 |
|
39 |
25 |
$3K |
| D0274 |
Bitewings - four radiographic images |
72 |
63 |
$2K |
| D7510 |
|
17 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
30 |
24 |
$176.00 |
| D1120 |
Prophylaxis - child |
17 |
14 |
$138.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
13 |
$55.50 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
12 |
$0.00 |