| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,561 |
1,548 |
$36K |
| D1120 |
Prophylaxis - child |
1,015 |
1,001 |
$35K |
| D1110 |
Prophylaxis - adult |
638 |
635 |
$28K |
| D0272 |
Bitewings - two radiographic images |
891 |
881 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
806 |
806 |
$16K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
422 |
377 |
$15K |
| D0274 |
Bitewings - four radiographic images |
476 |
470 |
$13K |
| D1206 |
Topical application of fluoride varnish |
236 |
234 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
319 |
305 |
$4K |
| D1351 |
Sealant - per tooth |
83 |
25 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
13 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
120 |
110 |
$736.89 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$657.60 |
| D0602 |
|
139 |
139 |
$0.00 |
| D0603 |
|
727 |
725 |
$0.00 |
| D1330 |
|
1,532 |
1,518 |
$0.00 |