| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
891 |
889 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,056 |
1,052 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
381 |
168 |
$7K |
| D1120 |
Prophylaxis - child |
1,138 |
1,137 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
207 |
103 |
$989.34 |
| D1110 |
Prophylaxis - adult |
199 |
198 |
$855.90 |
| D0330 |
Panoramic radiographic image |
129 |
129 |
$558.06 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
99 |
95 |
$122.42 |
| D0272 |
Bitewings - two radiographic images |
290 |
290 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
1,311 |
1,308 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
497 |
497 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
120 |
118 |
$0.00 |
| D1351 |
Sealant - per tooth |
587 |
141 |
$0.00 |
| D1330 |
|
1,320 |
1,318 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
39 |
13 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
1,186 |
1,174 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
183 |
182 |
$0.00 |
| D1354 |
|
83 |
24 |
$0.00 |