| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,506 |
3,494 |
$195K |
| D1120 |
Prophylaxis - child |
4,095 |
4,073 |
$167K |
| D0230 |
Intraoral - periapical each additional radiographic image |
19,319 |
4,403 |
$77K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,720 |
4,695 |
$66K |
| D0274 |
Bitewings - four radiographic images |
2,488 |
2,487 |
$52K |
| D1310 |
|
831 |
829 |
$38K |
| D8670 |
Periodic orthodontic treatment visit |
103 |
103 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
210 |
210 |
$11K |
| D0603 |
|
677 |
675 |
$10K |
| D9993 |
|
188 |
188 |
$9K |
| D0272 |
Bitewings - two radiographic images |
616 |
615 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
173 |
170 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
87 |
53 |
$6K |
| D1351 |
Sealant - per tooth |
172 |
51 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
83 |
83 |
$4K |
| D1110 |
Prophylaxis - adult |
24 |
24 |
$2K |
| D0350 |
|
94 |
65 |
$802.80 |
| D0220 |
Intraoral - periapical first radiographic image |
26 |
26 |
$312.00 |