| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
790 |
780 |
$50K |
| D1120 |
Prophylaxis - child |
1,259 |
1,254 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
650 |
650 |
$34K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,113 |
1,353 |
$21K |
| D9993 |
|
245 |
245 |
$16K |
| D1310 |
|
308 |
308 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
742 |
741 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
103 |
52 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
118 |
69 |
$6K |
| D1206 |
Topical application of fluoride varnish |
294 |
294 |
$5K |
| D1351 |
Sealant - per tooth |
160 |
40 |
$5K |
| D0272 |
Bitewings - two radiographic images |
321 |
321 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
67 |
66 |
$3K |
| D0350 |
|
217 |
82 |
$2K |
| D0603 |
|
133 |
133 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
42 |
41 |
$2K |
| D0274 |
Bitewings - four radiographic images |
78 |
77 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
15 |
15 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
43 |
43 |
$504.00 |
| D9430 |
|
13 |
12 |
$416.00 |
| D1330 |
|
91 |
91 |
$0.00 |