| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2750 |
|
279 |
202 |
$82K |
| D1110 |
Prophylaxis - adult |
2,920 |
2,891 |
$38K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,110 |
537 |
$37K |
| D0140 |
Limited oral evaluation - problem focused |
1,363 |
1,238 |
$25K |
| D2952 |
|
267 |
193 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
1,844 |
1,818 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,595 |
1,588 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
1,006 |
993 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,978 |
1,944 |
$14K |
| D4355 |
|
210 |
208 |
$12K |
| D0274 |
Bitewings - four radiographic images |
1,320 |
1,304 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
2,383 |
2,313 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,260 |
1,786 |
$5K |
| D0170 |
|
869 |
770 |
$4K |
| D1206 |
Topical application of fluoride varnish |
384 |
379 |
$3K |
| D2394 |
|
59 |
44 |
$2K |
| D1120 |
Prophylaxis - child |
249 |
248 |
$2K |
| D0601 |
|
312 |
311 |
$900.00 |
| D2335 |
|
18 |
12 |
$790.00 |
| D9920 |
|
81 |
81 |
$636.00 |
| D0350 |
|
334 |
268 |
$611.50 |
| D2332 |
|
17 |
12 |
$387.00 |