| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2750 |
|
487 |
314 |
$230K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
719 |
431 |
$96K |
| D1110 |
Prophylaxis - adult |
1,417 |
1,396 |
$92K |
| D0120 |
Periodic oral evaluation - established patient |
1,796 |
1,770 |
$56K |
| D1206 |
Topical application of fluoride varnish |
1,580 |
1,554 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
471 |
458 |
$26K |
| D2950 |
|
275 |
184 |
$23K |
| D0274 |
Bitewings - four radiographic images |
953 |
931 |
$22K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
128 |
74 |
$22K |
| D0330 |
Panoramic radiographic image |
391 |
380 |
$17K |
| D1120 |
Prophylaxis - child |
345 |
333 |
$15K |
| D4341 |
|
158 |
68 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
121 |
78 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
244 |
238 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,039 |
987 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
603 |
592 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
42 |
42 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
17 |
12 |
$2K |
| D1330 |
|
69 |
68 |
$408.00 |