| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
770 |
183 |
$166K |
| D0120 |
Periodic oral evaluation - established patient |
3,266 |
3,202 |
$77K |
| D1351 |
Sealant - per tooth |
3,923 |
897 |
$73K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,562 |
1,512 |
$69K |
| D0274 |
Bitewings - four radiographic images |
2,471 |
2,392 |
$65K |
| D1120 |
Prophylaxis - child |
3,059 |
3,009 |
$64K |
| D0330 |
Panoramic radiographic image |
964 |
933 |
$45K |
| D1110 |
Prophylaxis - adult |
1,450 |
1,418 |
$41K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,769 |
2,707 |
$30K |
| D1206 |
Topical application of fluoride varnish |
1,597 |
1,583 |
$21K |
| D0272 |
Bitewings - two radiographic images |
1,097 |
1,075 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
266 |
125 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
122 |
75 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
264 |
246 |
$7K |