| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,859 |
1,823 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
1,862 |
1,838 |
$27K |
| D0210 |
Intraoral - complete series of radiographic images |
376 |
373 |
$8K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
160 |
106 |
$5K |
| D0274 |
Bitewings - four radiographic images |
483 |
477 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
638 |
604 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
110 |
106 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
406 |
170 |
$827.75 |
| D2140 |
|
23 |
13 |
$544.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
12 |
$512.00 |