| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,740 |
1,740 |
$76K |
| D0210 |
Intraoral - complete series of radiographic images |
894 |
894 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,498 |
1,498 |
$35K |
| D0220 |
Intraoral - periapical first radiographic image |
1,342 |
1,328 |
$16K |
| D0274 |
Bitewings - four radiographic images |
651 |
651 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
600 |
600 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
835 |
833 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
261 |
260 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
29 |
24 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
13 |
$953.80 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
14 |
$487.00 |