| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
720 |
719 |
$49K |
| D0330 |
Panoramic radiographic image |
232 |
231 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
107 |
87 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
55 |
55 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
92 |
86 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$524.71 |
| D1351 |
Sealant - per tooth |
248 |
71 |
$522.60 |
| D0999 |
Unspecified diagnostic procedure, by report |
26 |
26 |
$520.00 |
| D1120 |
Prophylaxis - child |
563 |
559 |
$194.24 |
| D1110 |
Prophylaxis - adult |
300 |
300 |
$130.75 |
| D1208 |
Topical application of fluoride, excluding varnish |
916 |
912 |
$114.45 |
| D0220 |
Intraoral - periapical first radiographic image |
209 |
206 |
$98.11 |
| D0272 |
Bitewings - two radiographic images |
827 |
825 |
$66.90 |
| D1330 |
|
688 |
688 |
$6.00 |
| D9986 |
|
26 |
26 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
33 |
33 |
$0.00 |
| D0603 |
|
181 |
181 |
$0.00 |
| D0602 |
|
107 |
107 |
$0.00 |
| D0601 |
|
265 |
265 |
$0.00 |