| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0367 |
|
322 |
314 |
$95K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
554 |
252 |
$93K |
| D2394 |
|
471 |
284 |
$89K |
| D1110 |
Prophylaxis - adult |
890 |
869 |
$44K |
| D3120 |
|
919 |
442 |
$29K |
| D1206 |
Topical application of fluoride varnish |
1,332 |
1,293 |
$27K |
| D0274 |
Bitewings - four radiographic images |
754 |
744 |
$26K |
| D1320 |
|
668 |
654 |
$25K |
| D4910 |
|
409 |
380 |
$24K |
| D0330 |
Panoramic radiographic image |
405 |
396 |
$21K |
| D9110 |
|
271 |
251 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
514 |
504 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
196 |
193 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
96 |
92 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
125 |
123 |
$3K |
| D2950 |
|
19 |
14 |
$2K |
| D9630 |
|
95 |
90 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
106 |
43 |
$969.15 |