| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2750 |
|
422 |
333 |
$154K |
| D1110 |
Prophylaxis - adult |
1,896 |
1,896 |
$77K |
| D0120 |
Periodic oral evaluation - established patient |
2,204 |
2,204 |
$45K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
795 |
480 |
$43K |
| D0274 |
Bitewings - four radiographic images |
1,303 |
1,303 |
$27K |
| D0330 |
Panoramic radiographic image |
847 |
847 |
$24K |
| D2954 |
|
225 |
179 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,600 |
1,597 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
955 |
953 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,351 |
1,351 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
618 |
618 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
99 |
72 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
108 |
69 |
$4K |
| D1120 |
Prophylaxis - child |
97 |
97 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
173 |
172 |
$2K |