| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
372 |
351 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
404 |
372 |
$24K |
| D0274 |
Bitewings - four radiographic images |
405 |
383 |
$23K |
| D0330 |
Panoramic radiographic image |
212 |
196 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
101 |
49 |
$17K |
| D2740 |
Crown - porcelain/ceramic |
22 |
13 |
$7K |
| D1206 |
Topical application of fluoride varnish |
172 |
167 |
$5K |
| D2950 |
|
17 |
15 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
38 |
38 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
83 |
73 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
19 |
14 |
$254.04 |