| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
484 |
465 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
85 |
44 |
$9K |
| D1110 |
Prophylaxis - adult |
161 |
161 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
622 |
611 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
593 |
580 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
544 |
536 |
$6K |
| D0274 |
Bitewings - four radiographic images |
177 |
176 |
$6K |
| D1120 |
Prophylaxis - child |
80 |
80 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
49 |
42 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$317.88 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$280.56 |
| D0603 |
|
428 |
418 |
$18.02 |
| D0602 |
|
126 |
124 |
$0.00 |