| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
905 |
523 |
$140K |
| D1351 |
Sealant - per tooth |
1,360 |
608 |
$86K |
| D1120 |
Prophylaxis - child |
1,536 |
1,536 |
$64K |
| D0120 |
Periodic oral evaluation - established patient |
1,827 |
1,826 |
$52K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,622 |
1,622 |
$43K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
439 |
369 |
$28K |
| D0274 |
Bitewings - four radiographic images |
1,387 |
1,385 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
818 |
818 |
$21K |
| D9110 |
|
378 |
351 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
2,799 |
2,708 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,216 |
2,189 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
477 |
462 |
$9K |
| D1110 |
Prophylaxis - adult |
114 |
114 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
54 |
49 |
$3K |
| D4342 |
|
25 |
16 |
$3K |
| D0272 |
Bitewings - two radiographic images |
231 |
231 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
12 |
12 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
67 |
64 |
$696.78 |
| D0270 |
|
69 |
68 |
$386.40 |
| D0603 |
|
18 |
18 |
$0.00 |