| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
685 |
601 |
$28K |
| D0330 |
Panoramic radiographic image |
489 |
420 |
$21K |
| D0274 |
Bitewings - four radiographic images |
669 |
581 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
338 |
303 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
341 |
279 |
$9K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
20 |
13 |
$9K |
| D1206 |
Topical application of fluoride varnish |
379 |
312 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
321 |
271 |
$5K |
| D2950 |
|
12 |
12 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
14 |
14 |
$331.10 |