| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,229 |
1,186 |
$73K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
124 |
119 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
490 |
437 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
129 |
110 |
$8K |
| D1999 |
|
465 |
410 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
715 |
631 |
$5K |
| D1351 |
Sealant - per tooth |
164 |
62 |
$2K |
| D0272 |
Bitewings - two radiographic images |
382 |
370 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
78 |
40 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
12 |
$767.00 |
| D1120 |
Prophylaxis - child |
1,302 |
1,258 |
$747.36 |
| D0330 |
Panoramic radiographic image |
33 |
32 |
$298.72 |
| D0274 |
Bitewings - four radiographic images |
54 |
52 |
$234.47 |
| D0191 |
|
494 |
467 |
$229.90 |
| D1208 |
Topical application of fluoride, excluding varnish |
1,571 |
1,515 |
$16.42 |
| D1330 |
|
1,595 |
1,541 |
$3.00 |
| D1110 |
Prophylaxis - adult |
65 |
64 |
$0.00 |