| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
9,436 |
4,229 |
$424K |
| D0120 |
Periodic oral evaluation - established patient |
12,460 |
11,504 |
$333K |
| D1120 |
Prophylaxis - child |
8,458 |
8,232 |
$325K |
| D1206 |
Topical application of fluoride varnish |
8,382 |
8,156 |
$201K |
| D1110 |
Prophylaxis - adult |
1,646 |
1,548 |
$70K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,104 |
1,919 |
$45K |
| D0330 |
Panoramic radiographic image |
448 |
440 |
$11K |
| D0274 |
Bitewings - four radiographic images |
463 |
453 |
$8K |
| D4341 |
|
32 |
12 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
75 |
71 |
$392.00 |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$329.29 |
| D0230 |
Intraoral - periapical each additional radiographic image |
46 |
39 |
$317.10 |
| D0602 |
|
2,372 |
2,328 |
$0.00 |
| D0601 |
|
4,893 |
4,780 |
$0.00 |
| D0603 |
|
86 |
86 |
$0.00 |