| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1208 |
Topical application of fluoride, excluding varnish |
1,429 |
1,410 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,277 |
1,273 |
$32K |
| D1110 |
Prophylaxis - adult |
785 |
783 |
$29K |
| D1120 |
Prophylaxis - child |
982 |
980 |
$29K |
| D0274 |
Bitewings - four radiographic images |
907 |
905 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
551 |
548 |
$13K |
| D1999 |
|
1,236 |
1,104 |
$12K |
| D0272 |
Bitewings - two radiographic images |
655 |
653 |
$10K |
| D0240 |
|
482 |
250 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
46 |
29 |
$4K |
| D1351 |
Sealant - per tooth |
145 |
36 |
$3K |
| D1206 |
Topical application of fluoride varnish |
134 |
132 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
21 |
12 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$993.16 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$764.45 |
| D0220 |
Intraoral - periapical first radiographic image |
120 |
116 |
$714.29 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$264.00 |