| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
452 |
444 |
$24K |
| D0140 |
Limited oral evaluation - problem focused |
356 |
349 |
$19K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
17 |
15 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
161 |
157 |
$5K |
| D0274 |
Bitewings - four radiographic images |
106 |
103 |
$1K |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$950.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$406.25 |
| D0220 |
Intraoral - periapical first radiographic image |
28 |
26 |
$131.25 |
| D0230 |
Intraoral - periapical each additional radiographic image |
30 |
12 |
$71.25 |