| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,331 |
4,002 |
$177K |
| D1351 |
Sealant - per tooth |
2,431 |
1,138 |
$154K |
| D0120 |
Periodic oral evaluation - established patient |
5,324 |
4,884 |
$149K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,396 |
4,054 |
$114K |
| D4341 |
|
442 |
232 |
$61K |
| D0274 |
Bitewings - four radiographic images |
2,990 |
2,738 |
$53K |
| D1110 |
Prophylaxis - adult |
902 |
815 |
$37K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
470 |
304 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,428 |
1,275 |
$32K |
| D0220 |
Intraoral - periapical first radiographic image |
4,413 |
4,043 |
$27K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,310 |
3,744 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
620 |
563 |
$11K |
| D0272 |
Bitewings - two radiographic images |
759 |
702 |
$8K |
| D4342 |
|
18 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
13 |
$678.70 |
| D1206 |
Topical application of fluoride varnish |
13 |
12 |
$338.00 |
| D1999 |
|
1,203 |
1,097 |
$0.00 |