| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2750 |
|
530 |
386 |
$133K |
| D1110 |
Prophylaxis - adult |
5,332 |
5,289 |
$92K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,354 |
1,338 |
$75K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,946 |
2,922 |
$70K |
| D0120 |
Periodic oral evaluation - established patient |
4,272 |
4,230 |
$67K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,707 |
969 |
$67K |
| D0210 |
Intraoral - complete series of radiographic images |
2,280 |
2,264 |
$59K |
| D0274 |
Bitewings - four radiographic images |
3,861 |
3,822 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,980 |
4,819 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
5,632 |
5,518 |
$21K |
| D2950 |
|
389 |
297 |
$16K |
| D1120 |
Prophylaxis - child |
1,057 |
1,053 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
838 |
830 |
$8K |
| D4341 |
|
226 |
77 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
387 |
382 |
$6K |
| D1351 |
Sealant - per tooth |
403 |
90 |
$4K |
| D1206 |
Topical application of fluoride varnish |
187 |
186 |
$3K |
| D0190 |
|
256 |
253 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$616.00 |
| D1999 |
|
233 |
219 |
$0.00 |