| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
339 |
338 |
$28.00 |
| D1206 |
Topical application of fluoride varnish |
657 |
655 |
$15.00 |
| D1120 |
Prophylaxis - child |
1,410 |
1,380 |
$0.00 |
| D0330 |
Panoramic radiographic image |
398 |
388 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
837 |
804 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
601 |
596 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
293 |
200 |
$0.00 |
| D1110 |
Prophylaxis - adult |
442 |
439 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
259 |
200 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
1,339 |
1,228 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
385 |
268 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
769 |
746 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
182 |
182 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
1,678 |
1,563 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
595 |
500 |
$0.00 |
| D1351 |
Sealant - per tooth |
219 |
76 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
103 |
79 |
$0.00 |