| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,033 |
990 |
$48K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
596 |
551 |
$45K |
| D1110 |
Prophylaxis - adult |
208 |
206 |
$10K |
| D1120 |
Prophylaxis - child |
1,381 |
1,297 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,813 |
1,715 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,610 |
1,530 |
$5K |
| D1330 |
|
1,820 |
1,722 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
2,093 |
1,737 |
$2K |
| D1351 |
Sealant - per tooth |
620 |
150 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
209 |
206 |
$590.42 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
24 |
13 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
34 |
25 |
$0.00 |