| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,184 |
1,183 |
$34K |
| D1120 |
Prophylaxis - child |
900 |
899 |
$33K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,368 |
1,366 |
$20K |
| D1351 |
Sealant - per tooth |
623 |
177 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,277 |
1,271 |
$16K |
| D0272 |
Bitewings - two radiographic images |
674 |
674 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,215 |
1,214 |
$14K |
| D1110 |
Prophylaxis - adult |
218 |
218 |
$12K |
| D0274 |
Bitewings - four radiographic images |
230 |
230 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
68 |
29 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$459.16 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
16 |
12 |
$433.76 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$256.74 |
| D0601 |
|
1,099 |
1,098 |
$0.00 |
| D0603 |
|
171 |
171 |
$0.00 |