| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1208 |
Topical application of fluoride, excluding varnish |
6,998 |
6,901 |
$109K |
| D0120 |
Periodic oral evaluation - established patient |
6,078 |
6,012 |
$108K |
| D1120 |
Prophylaxis - child |
3,899 |
3,852 |
$104K |
| D1110 |
Prophylaxis - adult |
2,331 |
2,303 |
$82K |
| D0274 |
Bitewings - four radiographic images |
1,234 |
1,219 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
2,218 |
2,174 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
283 |
164 |
$16K |
| D0240 |
|
1,197 |
1,181 |
$15K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
654 |
623 |
$15K |
| D0272 |
Bitewings - two radiographic images |
818 |
803 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
177 |
113 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
376 |
370 |
$10K |
| D0330 |
Panoramic radiographic image |
201 |
184 |
$7K |
| D4910 |
|
78 |
77 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
46 |
46 |
$1K |
| D1351 |
Sealant - per tooth |
43 |
14 |
$792.91 |
| D0601 |
|
74 |
72 |
$350.00 |