| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
1,050 |
496 |
$211K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,212 |
1,073 |
$27K |
| D1120 |
Prophylaxis - child |
667 |
586 |
$26K |
| D1351 |
Sealant - per tooth |
411 |
183 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
798 |
749 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
222 |
133 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,947 |
1,743 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
156 |
94 |
$10K |
| D0274 |
Bitewings - four radiographic images |
520 |
483 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
306 |
271 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,588 |
1,444 |
$7K |
| D1206 |
Topical application of fluoride varnish |
255 |
223 |
$6K |
| D0330 |
Panoramic radiographic image |
240 |
203 |
$5K |
| D4342 |
|
26 |
15 |
$4K |
| D0272 |
Bitewings - two radiographic images |
264 |
231 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
255 |
203 |
$1K |
| D9110 |
|
12 |
12 |
$660.00 |
| D0270 |
|
81 |
70 |
$431.20 |
| D1110 |
Prophylaxis - adult |
15 |
13 |
$330.20 |
| D1999 |
|
79 |
50 |
$0.00 |