| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2750 |
|
136 |
124 |
$113K |
| D1110 |
Prophylaxis - adult |
2,013 |
2,012 |
$111K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,160 |
715 |
$102K |
| D0120 |
Periodic oral evaluation - established patient |
2,667 |
2,667 |
$73K |
| D0274 |
Bitewings - four radiographic images |
1,719 |
1,719 |
$47K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
364 |
298 |
$43K |
| D2740 |
Crown - porcelain/ceramic |
59 |
29 |
$29K |
| D0210 |
Intraoral - complete series of radiographic images |
429 |
426 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
668 |
668 |
$9K |
| D1120 |
Prophylaxis - child |
125 |
125 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
20 |
13 |
$2K |
| D0330 |
Panoramic radiographic image |
49 |
49 |
$2K |
| D0272 |
Bitewings - two radiographic images |
53 |
53 |
$846.94 |