| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,967 |
2,965 |
$247K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,118 |
1,082 |
$169K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,286 |
2,283 |
$140K |
| D2140 |
|
2,490 |
909 |
$135K |
| D0120 |
Periodic oral evaluation - established patient |
2,500 |
2,496 |
$125K |
| D4341 |
|
1,702 |
460 |
$114K |
| D0210 |
Intraoral - complete series of radiographic images |
1,567 |
1,564 |
$72K |
| D0350 |
|
7,385 |
2,424 |
$66K |
| D0274 |
Bitewings - four radiographic images |
3,094 |
3,083 |
$63K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,549 |
4,538 |
$55K |
| D0230 |
Intraoral - periapical each additional radiographic image |
13,359 |
2,315 |
$55K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
766 |
453 |
$51K |
| D1120 |
Prophylaxis - child |
1,531 |
1,528 |
$48K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
533 |
351 |
$36K |
| D1320 |
|
558 |
558 |
$10K |
| D1351 |
Sealant - per tooth |
323 |
62 |
$6K |
| D2330 |
|
75 |
46 |
$6K |
| D4910 |
|
30 |
30 |
$2K |