| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2750 |
|
171 |
71 |
$74K |
| D1110 |
Prophylaxis - adult |
440 |
440 |
$19K |
| D2954 |
|
98 |
60 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
456 |
456 |
$10K |
| D0274 |
Bitewings - four radiographic images |
298 |
298 |
$6K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
17 |
15 |
$5K |
| D0330 |
Panoramic radiographic image |
150 |
150 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
387 |
384 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
264 |
264 |
$3K |
| D9110 |
|
85 |
85 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$269.28 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$141.70 |