| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2750 |
|
43 |
24 |
$22K |
| D1110 |
Prophylaxis - adult |
93 |
89 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
57 |
57 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
69 |
66 |
$3K |
| D0274 |
Bitewings - four radiographic images |
74 |
74 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
65 |
65 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
46 |
46 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
75 |
73 |
$1K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$828.00 |