| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1208 |
Topical application of fluoride, excluding varnish |
3,229 |
3,030 |
$67K |
| D0120 |
Periodic oral evaluation - established patient |
1,954 |
1,923 |
$45K |
| D1110 |
Prophylaxis - adult |
1,075 |
1,059 |
$37K |
| D1120 |
Prophylaxis - child |
1,225 |
1,216 |
$33K |
| D1999 |
|
2,106 |
2,012 |
$20K |
| D0272 |
Bitewings - two radiographic images |
1,429 |
1,423 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
2,404 |
2,358 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,275 |
2,208 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
408 |
406 |
$9K |
| D0274 |
Bitewings - four radiographic images |
398 |
380 |
$8K |
| D1351 |
Sealant - per tooth |
115 |
22 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
31 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
28 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
36 |
36 |
$372.31 |