| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,788 |
2,782 |
$79K |
| D1120 |
Prophylaxis - child |
2,067 |
2,062 |
$75K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,116 |
3,108 |
$45K |
| D0272 |
Bitewings - two radiographic images |
1,357 |
1,352 |
$26K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
307 |
291 |
$8K |
| D1351 |
Sealant - per tooth |
279 |
68 |
$7K |
| D1110 |
Prophylaxis - adult |
85 |
85 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
376 |
371 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
252 |
160 |
$3K |
| D0274 |
Bitewings - four radiographic images |
87 |
87 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
30 |
24 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$847.68 |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$127.56 |
| D0603 |
|
4,280 |
4,250 |
$0.00 |