| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
4,661 |
863 |
$156K |
| D1120 |
Prophylaxis - child |
2,731 |
2,730 |
$108K |
| D0120 |
Periodic oral evaluation - established patient |
2,280 |
2,279 |
$86K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,496 |
1,496 |
$82K |
| D0274 |
Bitewings - four radiographic images |
3,135 |
3,134 |
$71K |
| D1110 |
Prophylaxis - adult |
813 |
813 |
$67K |
| D2740 |
Crown - porcelain/ceramic |
66 |
41 |
$57K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
407 |
156 |
$56K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,751 |
3,750 |
$47K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
235 |
131 |
$42K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,927 |
4,126 |
$36K |
| D4341 |
|
284 |
123 |
$33K |
| D0220 |
Intraoral - periapical first radiographic image |
2,027 |
1,927 |
$28K |
| D0350 |
|
2,042 |
470 |
$20K |
| D0330 |
Panoramic radiographic image |
194 |
190 |
$7K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
58 |
24 |
$4K |
| D0272 |
Bitewings - two radiographic images |
185 |
185 |
$2K |
| D1999 |
|
36 |
35 |
$37.70 |