| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
73 |
73 |
$61.90 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
234 |
234 |
$46.28 |
| D1120 |
Prophylaxis - child |
377 |
375 |
$44.44 |
| D0272 |
Bitewings - two radiographic images |
129 |
129 |
$23.90 |
| D1208 |
Topical application of fluoride, excluding varnish |
392 |
390 |
$20.93 |
| D0230 |
Intraoral - periapical each additional radiographic image |
358 |
352 |
$12.23 |
| D0220 |
Intraoral - periapical first radiographic image |
372 |
370 |
$0.00 |
| D1354 |
|
219 |
74 |
$0.00 |
| D1110 |
Prophylaxis - adult |
43 |
43 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
55 |
55 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
15 |
13 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
168 |
168 |
$0.00 |
| D1351 |
Sealant - per tooth |
52 |
16 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
100 |
28 |
$0.00 |