| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,449 |
2,423 |
$230K |
| D1120 |
Prophylaxis - child |
2,341 |
2,313 |
$21K |
| D0272 |
Bitewings - two radiographic images |
1,897 |
1,874 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
162 |
162 |
$14K |
| D1206 |
Topical application of fluoride varnish |
2,762 |
2,728 |
$14K |
| D1351 |
Sealant - per tooth |
219 |
41 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
12 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
157 |
76 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
212 |
194 |
$1K |
| D0274 |
Bitewings - four radiographic images |
79 |
79 |
$471.37 |
| D0330 |
Panoramic radiographic image |
91 |
90 |
$275.17 |
| D0230 |
Intraoral - periapical each additional radiographic image |
96 |
87 |
$232.55 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
25 |
24 |
$49.48 |
| D1110 |
Prophylaxis - adult |
25 |
24 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
40 |
40 |
$0.00 |