| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,794 |
1,792 |
$99K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
124 |
124 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
221 |
123 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
35 |
33 |
$5K |
| D0330 |
Panoramic radiographic image |
43 |
43 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
998 |
991 |
$3K |
| D1120 |
Prophylaxis - child |
1,409 |
1,408 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,840 |
1,840 |
$2K |
| D1330 |
|
1,998 |
1,996 |
$2K |
| D0272 |
Bitewings - two radiographic images |
854 |
853 |
$1K |
| D1351 |
Sealant - per tooth |
1,241 |
290 |
$1K |
| D0240 |
|
1,067 |
856 |
$1K |
| D1110 |
Prophylaxis - adult |
521 |
521 |
$938.15 |
| D0274 |
Bitewings - four radiographic images |
866 |
865 |
$670.22 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
51 |
40 |
$669.82 |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$648.02 |
| D0230 |
Intraoral - periapical each additional radiographic image |
934 |
927 |
$534.70 |
| D1999 |
|
12 |
12 |
$500.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$245.00 |
| D1206 |
Topical application of fluoride varnish |
87 |
86 |
$0.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
50 |
50 |
$0.00 |