| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2750 |
|
419 |
227 |
$284K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,064 |
813 |
$173K |
| D1110 |
Prophylaxis - adult |
2,689 |
2,689 |
$140K |
| D0120 |
Periodic oral evaluation - established patient |
3,356 |
3,355 |
$108K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
296 |
255 |
$47K |
| D0274 |
Bitewings - four radiographic images |
1,281 |
1,281 |
$45K |
| D0220 |
Intraoral - periapical first radiographic image |
1,405 |
1,363 |
$24K |
| D2394 |
|
82 |
78 |
$14K |
| D2332 |
|
55 |
52 |
$11K |
| D2331 |
|
63 |
54 |
$10K |
| D2954 |
|
33 |
24 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
153 |
151 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
266 |
266 |
$6K |
| D0330 |
Panoramic radiographic image |
90 |
90 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
150 |
150 |
$4K |
| D1120 |
Prophylaxis - child |
64 |
64 |
$2K |
| D9110 |
|
66 |
66 |
$2K |