| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
314 |
301 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
32 |
29 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
31 |
30 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
29 |
28 |
$826.44 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
12 |
$383.00 |
| D1120 |
Prophylaxis - child |
303 |
289 |
$205.78 |
| D1208 |
Topical application of fluoride, excluding varnish |
386 |
369 |
$110.18 |
| D0272 |
Bitewings - two radiographic images |
304 |
294 |
$103.00 |
| D1110 |
Prophylaxis - adult |
45 |
44 |
$80.00 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
15 |
$16.00 |
| D0220 |
Intraoral - periapical first radiographic image |
334 |
323 |
$7.00 |
| D0330 |
Panoramic radiographic image |
66 |
65 |
$0.00 |
| D0350 |
|
17 |
14 |
$0.00 |
| D1330 |
|
382 |
366 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
327 |
316 |
$0.00 |
| D0603 |
|
18 |
12 |
$0.00 |
| D1351 |
Sealant - per tooth |
145 |
31 |
$0.00 |
| D0602 |
|
33 |
30 |
$0.00 |