| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,774 |
3,774 |
$128K |
| D0120 |
Periodic oral evaluation - established patient |
3,011 |
3,011 |
$59K |
| D0274 |
Bitewings - four radiographic images |
2,654 |
2,654 |
$49K |
| D0210 |
Intraoral - complete series of radiographic images |
2,436 |
2,359 |
$42K |
| D0220 |
Intraoral - periapical first radiographic image |
3,209 |
3,168 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,318 |
1,318 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,887 |
2,882 |
$26K |
| D2750 |
|
52 |
26 |
$15K |
| D0330 |
Panoramic radiographic image |
184 |
184 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
113 |
113 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
22 |
12 |
$1K |