| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
685 |
620 |
$60K |
| D1110 |
Prophylaxis - adult |
589 |
561 |
$48K |
| D2740 |
Crown - porcelain/ceramic |
79 |
53 |
$43K |
| D0274 |
Bitewings - four radiographic images |
797 |
723 |
$42K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
256 |
126 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
643 |
582 |
$38K |
| D1206 |
Topical application of fluoride varnish |
711 |
675 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
117 |
71 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
307 |
303 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
434 |
413 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
77 |
77 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$2K |
| D1120 |
Prophylaxis - child |
15 |
13 |
$844.35 |