| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
911 |
883 |
$39K |
| D0330 |
Panoramic radiographic image |
734 |
717 |
$28K |
| D1206 |
Topical application of fluoride varnish |
1,034 |
1,003 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
616 |
603 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
183 |
71 |
$14K |
| D0274 |
Bitewings - four radiographic images |
725 |
710 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
429 |
417 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,640 |
861 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,126 |
1,070 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
71 |
25 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
239 |
228 |
$4K |
| D4355 |
|
51 |
41 |
$3K |