| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1355 |
|
4,890 |
471 |
$422K |
| D0120 |
Periodic oral evaluation - established patient |
4,516 |
4,013 |
$84K |
| D1110 |
Prophylaxis - adult |
2,008 |
1,800 |
$80K |
| D1354 |
|
917 |
189 |
$76K |
| D0274 |
Bitewings - four radiographic images |
2,661 |
2,370 |
$74K |
| D1120 |
Prophylaxis - child |
2,304 |
2,048 |
$57K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,398 |
2,999 |
$57K |
| D0330 |
Panoramic radiographic image |
1,285 |
1,101 |
$50K |
| D4346 |
|
325 |
280 |
$50K |
| D0210 |
Intraoral - complete series of radiographic images |
1,235 |
1,160 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,325 |
1,184 |
$38K |
| D0140 |
Limited oral evaluation - problem focused |
621 |
547 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
281 |
160 |
$17K |
| D1351 |
Sealant - per tooth |
638 |
76 |
$9K |
| D0272 |
Bitewings - two radiographic images |
339 |
299 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
145 |
82 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
168 |
146 |
$2K |
| D4910 |
|
27 |
12 |
$153.00 |