| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2752 |
|
158 |
58 |
$56K |
| D1110 |
Prophylaxis - adult |
494 |
493 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
525 |
524 |
$10K |
| D4249 |
|
54 |
41 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
235 |
228 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
202 |
201 |
$2K |
| D2954 |
|
19 |
14 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
311 |
302 |
$2K |
| D0274 |
Bitewings - four radiographic images |
132 |
132 |
$2K |
| D0330 |
Panoramic radiographic image |
47 |
47 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
29 |
29 |
$1K |
| D4342 |
|
50 |
24 |
$990.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
16 |
$334.56 |