| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
464 |
431 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
231 |
222 |
$6K |
| D1110 |
Prophylaxis - adult |
333 |
324 |
$5K |
| D1206 |
Topical application of fluoride varnish |
794 |
770 |
$5K |
| D0330 |
Panoramic radiographic image |
392 |
360 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
124 |
49 |
$4K |
| D1120 |
Prophylaxis - child |
147 |
147 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
33 |
25 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,072 |
665 |
$1K |
| D1330 |
|
339 |
335 |
$787.12 |
| D0240 |
|
42 |
37 |
$539.28 |
| D0350 |
|
370 |
338 |
$328.55 |
| D0220 |
Intraoral - periapical first radiographic image |
767 |
717 |
$304.60 |
| D4346 |
|
16 |
16 |
$260.90 |
| D1351 |
Sealant - per tooth |
118 |
27 |
$230.42 |
| D0274 |
Bitewings - four radiographic images |
396 |
370 |
$193.00 |
| D4921 |
|
23 |
19 |
$92.13 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$91.88 |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
16 |
$40.16 |
| D1310 |
|
286 |
282 |
$0.00 |