| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2750 |
|
511 |
276 |
$247K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,101 |
462 |
$146K |
| D1110 |
Prophylaxis - adult |
1,100 |
1,086 |
$72K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
608 |
283 |
$62K |
| D2950 |
|
497 |
277 |
$42K |
| D1206 |
Topical application of fluoride varnish |
1,359 |
1,347 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
629 |
616 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
984 |
973 |
$31K |
| D0210 |
Intraoral - complete series of radiographic images |
429 |
417 |
$24K |
| D4341 |
|
190 |
66 |
$17K |
| D1120 |
Prophylaxis - child |
290 |
286 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
77 |
53 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
230 |
217 |
$11K |
| D0274 |
Bitewings - four radiographic images |
305 |
304 |
$7K |
| D1351 |
Sealant - per tooth |
201 |
38 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
465 |
456 |
$5K |
| D0330 |
Panoramic radiographic image |
70 |
70 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
362 |
360 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
14 |
12 |
$2K |
| D1330 |
|
125 |
125 |
$862.80 |
| D0272 |
Bitewings - two radiographic images |
28 |
28 |
$459.48 |