| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
830 |
830 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
931 |
929 |
$23K |
| D0274 |
Bitewings - four radiographic images |
375 |
375 |
$11K |
| D2740 |
Crown - porcelain/ceramic |
13 |
12 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
523 |
519 |
$8K |
| D1120 |
Prophylaxis - child |
179 |
179 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
172 |
172 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
232 |
232 |
$6K |
| D0330 |
Panoramic radiographic image |
86 |
86 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
32 |
26 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
503 |
419 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
12 |
$2K |