| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,120 |
2,119 |
$96K |
| D0210 |
Intraoral - complete series of radiographic images |
913 |
910 |
$39K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
582 |
427 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,279 |
1,278 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,221 |
1,221 |
$29K |
| D0274 |
Bitewings - four radiographic images |
658 |
657 |
$15K |
| D2140 |
|
364 |
241 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
164 |
113 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
586 |
586 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
480 |
476 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
112 |
90 |
$4K |
| D2160 |
|
28 |
26 |
$3K |
| D1120 |
Prophylaxis - child |
50 |
50 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
44 |
26 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
135 |
135 |
$1K |