| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
363 |
358 |
$8K |
| D1120 |
Prophylaxis - child |
279 |
279 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
818 |
501 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
53 |
37 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
629 |
608 |
$3K |
| D1206 |
Topical application of fluoride varnish |
196 |
196 |
$3K |
| D0274 |
Bitewings - four radiographic images |
148 |
147 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
182 |
180 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
25 |
24 |
$1K |
| D1110 |
Prophylaxis - adult |
28 |
27 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
38 |
38 |
$671.08 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13 |
12 |
$630.00 |
| D0272 |
Bitewings - two radiographic images |
66 |
66 |
$476.87 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$0.00 |
| D0602 |
|
13 |
13 |
$0.00 |
| D0601 |
|
13 |
13 |
$0.00 |