| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2752 |
|
279 |
184 |
$152K |
| D1110 |
Prophylaxis - adult |
1,639 |
1,639 |
$89K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
930 |
384 |
$73K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
543 |
317 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
1,604 |
1,604 |
$44K |
| D0210 |
Intraoral - complete series of radiographic images |
510 |
509 |
$22K |
| D0274 |
Bitewings - four radiographic images |
745 |
745 |
$20K |
| D2954 |
|
108 |
61 |
$15K |
| D1120 |
Prophylaxis - child |
275 |
275 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
345 |
345 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
614 |
614 |
$9K |
| D2394 |
|
43 |
25 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
263 |
263 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
48 |
26 |
$2K |
| D2332 |
|
15 |
12 |
$2K |
| D2331 |
|
16 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
52 |
52 |
$631.68 |