| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1208 |
Topical application of fluoride, excluding varnish |
1,426 |
1,405 |
$29K |
| D1120 |
Prophylaxis - child |
864 |
853 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
962 |
945 |
$19K |
| D1110 |
Prophylaxis - adult |
283 |
272 |
$13K |
| D0274 |
Bitewings - four radiographic images |
463 |
458 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
489 |
460 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
371 |
302 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
75 |
75 |
$2K |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$1K |
| D1351 |
Sealant - per tooth |
34 |
12 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
12 |
12 |
$404.88 |