| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
9,425 |
9,122 |
$294K |
| D1120 |
Prophylaxis - child |
6,765 |
6,502 |
$250K |
| D1110 |
Prophylaxis - adult |
3,154 |
3,034 |
$168K |
| D1208 |
Topical application of fluoride, excluding varnish |
9,089 |
8,765 |
$168K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
972 |
610 |
$107K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
865 |
561 |
$82K |
| D0272 |
Bitewings - two radiographic images |
2,648 |
2,548 |
$70K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
369 |
340 |
$20K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
309 |
278 |
$13K |
| D1351 |
Sealant - per tooth |
298 |
100 |
$9K |
| D0330 |
Panoramic radiographic image |
129 |
123 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$754.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$395.88 |