| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2750 |
|
417 |
260 |
$265K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,511 |
731 |
$182K |
| D1110 |
Prophylaxis - adult |
1,812 |
1,810 |
$93K |
| D0120 |
Periodic oral evaluation - established patient |
2,000 |
1,999 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
698 |
697 |
$30K |
| D1120 |
Prophylaxis - child |
804 |
804 |
$29K |
| D0274 |
Bitewings - four radiographic images |
802 |
802 |
$26K |
| D0210 |
Intraoral - complete series of radiographic images |
321 |
320 |
$25K |
| D1206 |
Topical application of fluoride varnish |
947 |
947 |
$21K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
86 |
55 |
$13K |
| D2950 |
|
76 |
55 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
258 |
255 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
26 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
133 |
121 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
24 |
24 |
$1K |