| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
504 |
502 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
90 |
90 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
378 |
345 |
$6K |
| D2140 |
|
32 |
15 |
$2K |
| D0272 |
Bitewings - two radiographic images |
73 |
73 |
$2K |
| D1110 |
Prophylaxis - adult |
39 |
39 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
20 |
12 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
72 |
72 |
$1K |
| D9110 |
|
12 |
12 |
$418.18 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13 |
12 |
$319.20 |
| D0230 |
Intraoral - periapical each additional radiographic image |
16 |
15 |
$199.50 |