| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,367 |
3,351 |
$202K |
| D1120 |
Prophylaxis - child |
3,607 |
3,586 |
$145K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,193 |
3,173 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
642 |
640 |
$40K |
| D0210 |
Intraoral - complete series of radiographic images |
724 |
721 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,740 |
2,825 |
$26K |
| D0274 |
Bitewings - four radiographic images |
1,097 |
1,088 |
$22K |
| D1206 |
Topical application of fluoride varnish |
1,117 |
1,117 |
$18K |
| D1110 |
Prophylaxis - adult |
207 |
207 |
$18K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
431 |
398 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
241 |
141 |
$16K |
| D0272 |
Bitewings - two radiographic images |
724 |
719 |
$8K |
| D0350 |
|
329 |
183 |
$3K |
| D4910 |
|
41 |
41 |
$3K |
| D1351 |
Sealant - per tooth |
37 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
88 |
84 |
$948.00 |
| D1330 |
|
19 |
19 |
$0.00 |