| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,786 |
1,761 |
$121K |
| D1120 |
Prophylaxis - child |
1,610 |
1,586 |
$37K |
| D0272 |
Bitewings - two radiographic images |
1,185 |
1,172 |
$24K |
| D1206 |
Topical application of fluoride varnish |
1,572 |
1,551 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
12 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
13 |
$1K |
| D0274 |
Bitewings - four radiographic images |
37 |
37 |
$968.96 |
| D0220 |
Intraoral - periapical first radiographic image |
55 |
53 |
$757.46 |
| D1110 |
Prophylaxis - adult |
15 |
15 |
$256.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
32 |
29 |
$0.00 |