| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
233 |
219 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
345 |
342 |
$9K |
| D1120 |
Prophylaxis - child |
586 |
573 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
138 |
121 |
$6K |
| D1206 |
Topical application of fluoride varnish |
577 |
561 |
$4K |
| D1351 |
Sealant - per tooth |
357 |
89 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
55 |
29 |
$2K |
| D1330 |
|
643 |
630 |
$2K |
| D0240 |
|
373 |
271 |
$1K |
| D0272 |
Bitewings - two radiographic images |
174 |
172 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
291 |
130 |
$531.14 |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$490.69 |
| D0220 |
Intraoral - periapical first radiographic image |
229 |
207 |
$458.30 |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
15 |
$245.25 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$228.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$200.00 |
| D0274 |
Bitewings - four radiographic images |
15 |
15 |
$81.75 |