| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
472 |
468 |
$5K |
| D1110 |
Prophylaxis - adult |
92 |
92 |
$4K |
| D0603 |
|
470 |
465 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
225 |
222 |
$2K |
| D0330 |
Panoramic radiographic image |
17 |
17 |
$1K |
| D1120 |
Prophylaxis - child |
432 |
427 |
$112.22 |
| D1206 |
Topical application of fluoride varnish |
556 |
552 |
$21.26 |
| D1330 |
|
574 |
569 |
$0.00 |
| D0240 |
|
39 |
39 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
29 |
29 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
191 |
190 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
279 |
275 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
63 |
55 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
104 |
104 |
$0.00 |