| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,376 |
1,373 |
$115K |
| D0120 |
Periodic oral evaluation - established patient |
1,779 |
1,768 |
$93K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
648 |
647 |
$40K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
531 |
313 |
$35K |
| D1120 |
Prophylaxis - child |
759 |
758 |
$29K |
| D0210 |
Intraoral - complete series of radiographic images |
597 |
595 |
$27K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,484 |
1,902 |
$26K |
| D2791 |
|
38 |
27 |
$18K |
| D0272 |
Bitewings - two radiographic images |
1,084 |
1,080 |
$12K |
| D2140 |
|
139 |
85 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
606 |
606 |
$7K |
| D2160 |
|
22 |
17 |
$2K |
| D2954 |
|
13 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
50 |
50 |
$1K |