| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,664 |
3,640 |
$143K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,470 |
682 |
$106K |
| D0330 |
Panoramic radiographic image |
2,096 |
2,075 |
$104K |
| D0120 |
Periodic oral evaluation - established patient |
3,295 |
3,278 |
$54K |
| D1206 |
Topical application of fluoride varnish |
2,786 |
2,771 |
$53K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
641 |
396 |
$53K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,601 |
1,584 |
$46K |
| D0274 |
Bitewings - four radiographic images |
1,749 |
1,738 |
$41K |
| D1120 |
Prophylaxis - child |
955 |
949 |
$31K |
| D0140 |
Limited oral evaluation - problem focused |
978 |
960 |
$22K |
| D9994 |
|
3,007 |
2,978 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,076 |
1,050 |
$10K |
| D9992 |
|
714 |
705 |
$6K |
| D2950 |
|
29 |
27 |
$4K |
| D2332 |
|
32 |
14 |
$3K |
| D4355 |
|
13 |
13 |
$1K |
| D9310 |
|
12 |
12 |
$998.28 |
| D9630 |
|
38 |
38 |
$735.19 |