| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
10,907 |
10,889 |
$261K |
| D1120 |
Prophylaxis - child |
7,275 |
7,258 |
$245K |
| D1206 |
Topical application of fluoride varnish |
10,764 |
10,731 |
$212K |
| D1110 |
Prophylaxis - adult |
3,090 |
3,083 |
$150K |
| D0272 |
Bitewings - two radiographic images |
3,268 |
3,261 |
$67K |
| D0220 |
Intraoral - periapical first radiographic image |
2,182 |
2,153 |
$27K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
651 |
611 |
$20K |
| D0274 |
Bitewings - four radiographic images |
349 |
349 |
$11K |
| D1351 |
Sealant - per tooth |
251 |
77 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
61 |
26 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
194 |
194 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
28 |
$1K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$698.60 |