| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
323 |
316 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
421 |
410 |
$4K |
| D1351 |
Sealant - per tooth |
640 |
155 |
$275.31 |
| D0230 |
Intraoral - periapical each additional radiographic image |
497 |
490 |
$194.13 |
| D1120 |
Prophylaxis - child |
423 |
411 |
$90.78 |
| D0274 |
Bitewings - four radiographic images |
239 |
232 |
$32.33 |
| D1330 |
|
556 |
545 |
$20.85 |
| D1206 |
Topical application of fluoride varnish |
546 |
534 |
$12.26 |
| D0220 |
Intraoral - periapical first radiographic image |
528 |
516 |
$7.81 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
130 |
115 |
$0.00 |
| D1110 |
Prophylaxis - adult |
89 |
88 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
125 |
78 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
153 |
153 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
193 |
108 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
222 |
95 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
108 |
108 |
$0.00 |
| D7111 |
|
51 |
24 |
$0.00 |