| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,882 |
1,846 |
$88K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
625 |
293 |
$77K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
504 |
208 |
$76K |
| D2750 |
|
126 |
85 |
$61K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,072 |
1,050 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,071 |
1,055 |
$28K |
| D0274 |
Bitewings - four radiographic images |
1,090 |
1,075 |
$21K |
| D0330 |
Panoramic radiographic image |
285 |
283 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
287 |
282 |
$10K |
| D1206 |
Topical application of fluoride varnish |
349 |
337 |
$9K |
| D2950 |
|
95 |
60 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
827 |
793 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
92 |
85 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
12 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
25 |
25 |
$603.98 |
| D0230 |
Intraoral - periapical each additional radiographic image |
26 |
26 |
$326.63 |