| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2722 |
|
284 |
135 |
$246K |
| D6750 |
|
199 |
62 |
$177K |
| D6240 |
|
115 |
61 |
$103K |
| D2950 |
|
350 |
173 |
$55K |
| D1110 |
Prophylaxis - adult |
1,027 |
1,016 |
$22K |
| D2140 |
|
717 |
187 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
948 |
938 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
174 |
174 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
135 |
71 |
$12K |
| D1206 |
Topical application of fluoride varnish |
1,061 |
1,053 |
$11K |
| D0274 |
Bitewings - four radiographic images |
789 |
779 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
156 |
69 |
$11K |
| D1120 |
Prophylaxis - child |
566 |
565 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
724 |
722 |
$8K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
245 |
105 |
$6K |
| D1330 |
|
159 |
159 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
231 |
228 |
$3K |
| D0272 |
Bitewings - two radiographic images |
189 |
189 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
321 |
298 |
$2K |
| D0330 |
Panoramic radiographic image |
28 |
28 |
$0.00 |