| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2750 |
|
231 |
143 |
$105K |
| D1110 |
Prophylaxis - adult |
685 |
682 |
$45K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
275 |
155 |
$38K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
326 |
155 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
560 |
555 |
$31K |
| D0210 |
Intraoral - complete series of radiographic images |
456 |
451 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
627 |
625 |
$20K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
49 |
25 |
$8K |
| D0274 |
Bitewings - four radiographic images |
309 |
309 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
152 |
148 |
$7K |
| D1120 |
Prophylaxis - child |
117 |
117 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
38 |
26 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
141 |
141 |
$3K |
| D1330 |
|
114 |
114 |
$732.00 |
| D0220 |
Intraoral - periapical first radiographic image |
50 |
48 |
$587.36 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$551.40 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$299.04 |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
14 |
$209.92 |