| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
767 |
767 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
829 |
829 |
$21K |
| D0274 |
Bitewings - four radiographic images |
1,031 |
1,030 |
$12K |
| D1206 |
Topical application of fluoride varnish |
387 |
387 |
$11K |
| D0330 |
Panoramic radiographic image |
264 |
264 |
$10K |
| D1120 |
Prophylaxis - child |
248 |
248 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
255 |
252 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
139 |
82 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
1,489 |
1,452 |
$7K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
13 |
12 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
242 |
242 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,190 |
1,178 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
75 |
39 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
78 |
78 |
$2K |