| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
823 |
796 |
$32K |
| D1120 |
Prophylaxis - child |
1,070 |
959 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
158 |
94 |
$17K |
| D1206 |
Topical application of fluoride varnish |
596 |
594 |
$14K |
| D1351 |
Sealant - per tooth |
373 |
116 |
$8K |
| D0330 |
Panoramic radiographic image |
198 |
198 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
81 |
81 |
$5K |
| D0274 |
Bitewings - four radiographic images |
308 |
274 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
136 |
118 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
410 |
342 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
61 |
43 |
$4K |
| D0272 |
Bitewings - two radiographic images |
297 |
270 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
108 |
108 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
88 |
86 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
183 |
182 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
104 |
82 |
$936.38 |
| D0120 |
Periodic oral evaluation - established patient |
67 |
28 |
$36.00 |