| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,480 |
632 |
$103K |
| D1120 |
Prophylaxis - child |
2,035 |
1,716 |
$80K |
| D4341 |
|
334 |
160 |
$57K |
| D0120 |
Periodic oral evaluation - established patient |
2,123 |
1,817 |
$57K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,041 |
1,718 |
$50K |
| D0274 |
Bitewings - four radiographic images |
1,857 |
1,602 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,095 |
930 |
$22K |
| D4342 |
|
236 |
123 |
$21K |
| D1110 |
Prophylaxis - adult |
430 |
385 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
2,098 |
1,817 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
535 |
484 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,763 |
1,500 |
$8K |
| D9110 |
|
103 |
94 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
80 |
60 |
$5K |
| D0272 |
Bitewings - two radiographic images |
470 |
389 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
12 |
12 |
$590.40 |
| D1999 |
|
516 |
509 |
$0.00 |