| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
426 |
422 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
18 |
18 |
$927.24 |
| D0272 |
Bitewings - two radiographic images |
303 |
301 |
$899.65 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
14 |
13 |
$854.41 |
| D0220 |
Intraoral - periapical first radiographic image |
297 |
294 |
$668.79 |
| D0340 |
|
16 |
16 |
$400.48 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
12 |
12 |
$307.81 |
| D0140 |
Limited oral evaluation - problem focused |
18 |
16 |
$286.73 |
| D1330 |
|
464 |
460 |
$243.02 |
| D0274 |
Bitewings - four radiographic images |
93 |
93 |
$238.69 |
| D0240 |
|
109 |
107 |
$190.17 |
| D0330 |
Panoramic radiographic image |
34 |
34 |
$111.92 |
| D1120 |
Prophylaxis - child |
346 |
344 |
$105.01 |
| D1206 |
Topical application of fluoride varnish |
452 |
448 |
$57.16 |
| D0230 |
Intraoral - periapical each additional radiographic image |
295 |
290 |
$20.00 |
| D1110 |
Prophylaxis - adult |
104 |
102 |
$0.00 |