| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
11,977 |
11,958 |
$621K |
| D1351 |
Sealant - per tooth |
11,580 |
3,980 |
$483K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
6,955 |
6,946 |
$404K |
| D1206 |
Topical application of fluoride varnish |
12,162 |
12,143 |
$326K |
| D0272 |
Bitewings - two radiographic images |
5,708 |
5,702 |
$176K |
| D0120 |
Periodic oral evaluation - established patient |
5,412 |
5,403 |
$161K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,423 |
954 |
$129K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,057 |
680 |
$100K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
780 |
588 |
$94K |
| D0274 |
Bitewings - four radiographic images |
1,481 |
1,479 |
$65K |
| D2140 |
|
500 |
362 |
$38K |
| D0220 |
Intraoral - periapical first radiographic image |
867 |
864 |
$17K |
| D1110 |
Prophylaxis - adult |
206 |
204 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
795 |
534 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
14 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
28 |
28 |
$812.00 |