| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2752 |
|
375 |
230 |
$208K |
| D1110 |
Prophylaxis - adult |
483 |
483 |
$19K |
| D2954 |
|
139 |
114 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
635 |
635 |
$13K |
| D0330 |
Panoramic radiographic image |
213 |
213 |
$6K |
| D4342 |
|
163 |
126 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
99 |
97 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
191 |
185 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
13 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
54 |
53 |
$503.72 |
| D1208 |
Topical application of fluoride, excluding varnish |
26 |
26 |
$284.60 |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$172.57 |