| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,031 |
5,917 |
$308K |
| D0120 |
Periodic oral evaluation - established patient |
8,286 |
8,148 |
$240K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,187 |
8,058 |
$240K |
| D1110 |
Prophylaxis - adult |
2,635 |
2,612 |
$183K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,857 |
1,369 |
$161K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,105 |
807 |
$123K |
| D0274 |
Bitewings - four radiographic images |
1,100 |
1,084 |
$47K |
| D9110 |
|
638 |
630 |
$46K |
| D0272 |
Bitewings - two radiographic images |
1,466 |
1,444 |
$44K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
328 |
270 |
$30K |
| D1351 |
Sealant - per tooth |
326 |
75 |
$13K |
| D2330 |
|
32 |
26 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
138 |
132 |
$3K |
| D2140 |
|
13 |
13 |
$864.60 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$754.00 |