| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,067 |
362 |
$84K |
| D8670 |
Periodic orthodontic treatment visit |
807 |
440 |
$70K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
850 |
225 |
$45K |
| D0140 |
Limited oral evaluation - problem focused |
729 |
569 |
$23K |
| D1120 |
Prophylaxis - child |
850 |
627 |
$17K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
206 |
79 |
$16K |
| D0350 |
|
635 |
129 |
$12K |
| D1206 |
Topical application of fluoride varnish |
558 |
356 |
$8K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
15 |
12 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
266 |
153 |
$6K |
| D0330 |
Panoramic radiographic image |
276 |
154 |
$5K |
| D0274 |
Bitewings - four radiographic images |
374 |
232 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
217 |
204 |
$3K |
| D2394 |
|
12 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
129 |
103 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$795.84 |
| D0470 |
|
56 |
12 |
$749.52 |
| D0340 |
|
14 |
12 |
$701.76 |