| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4355 |
|
1,243 |
1,239 |
$93K |
| D0140 |
Limited oral evaluation - problem focused |
2,891 |
2,717 |
$88K |
| D2394 |
|
267 |
147 |
$43K |
| D1351 |
Sealant - per tooth |
1,279 |
152 |
$40K |
| D0220 |
Intraoral - periapical first radiographic image |
2,510 |
2,407 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,884 |
1,892 |
$27K |
| D1110 |
Prophylaxis - adult |
635 |
634 |
$21K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
131 |
59 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
889 |
888 |
$19K |
| D0274 |
Bitewings - four radiographic images |
657 |
654 |
$17K |
| D1120 |
Prophylaxis - child |
317 |
317 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
448 |
448 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
168 |
168 |
$7K |
| D0240 |
|
162 |
81 |
$4K |
| D0272 |
Bitewings - two radiographic images |
82 |
82 |
$2K |
| D1206 |
Topical application of fluoride varnish |
40 |
40 |
$1K |