| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,324 |
2,324 |
$47K |
| D1110 |
Prophylaxis - adult |
1,037 |
1,037 |
$45K |
| D1120 |
Prophylaxis - child |
1,424 |
1,424 |
$42K |
| D0220 |
Intraoral - periapical first radiographic image |
2,106 |
1,954 |
$31K |
| D1206 |
Topical application of fluoride varnish |
1,718 |
1,718 |
$26K |
| D0274 |
Bitewings - four radiographic images |
470 |
470 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,737 |
1,554 |
$13K |
| D0350 |
|
318 |
221 |
$8K |
| D0330 |
Panoramic radiographic image |
173 |
173 |
$8K |
| D0272 |
Bitewings - two radiographic images |
376 |
376 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
206 |
206 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
108 |
94 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
25 |
25 |
$716.05 |