| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
411 |
409 |
$23K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
128 |
110 |
$9K |
| D1110 |
Prophylaxis - adult |
69 |
69 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
105 |
60 |
$4K |
| D0330 |
Panoramic radiographic image |
22 |
22 |
$3K |
| D1120 |
Prophylaxis - child |
307 |
304 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
18 |
18 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
14 |
$875.00 |
| D0220 |
Intraoral - periapical first radiographic image |
142 |
141 |
$346.00 |
| D0240 |
|
118 |
60 |
$277.00 |
| D1330 |
|
446 |
443 |
$216.39 |
| D1351 |
Sealant - per tooth |
101 |
27 |
$152.00 |
| D0272 |
Bitewings - two radiographic images |
118 |
118 |
$83.25 |
| D1208 |
Topical application of fluoride, excluding varnish |
220 |
217 |
$65.40 |
| D1206 |
Topical application of fluoride varnish |
172 |
171 |
$16.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
100 |
98 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$0.00 |