| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,536 |
1,531 |
$102K |
| D1120 |
Prophylaxis - child |
2,009 |
2,006 |
$90K |
| D1310 |
|
1,089 |
1,088 |
$49K |
| D1206 |
Topical application of fluoride varnish |
1,707 |
1,703 |
$30K |
| D9993 |
|
334 |
334 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
217 |
217 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,818 |
968 |
$12K |
| D0603 |
|
468 |
467 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
503 |
499 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
38 |
24 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
63 |
56 |
$3K |
| D0272 |
Bitewings - two radiographic images |
118 |
118 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$708.00 |
| D0601 |
|
14 |
14 |
$210.00 |