| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
795 |
765 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
912 |
884 |
$5K |
| D1110 |
Prophylaxis - adult |
161 |
160 |
$4K |
| D0274 |
Bitewings - four radiographic images |
224 |
224 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
61 |
37 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
134 |
124 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
236 |
236 |
$939.92 |
| D0230 |
Intraoral - periapical each additional radiographic image |
189 |
170 |
$700.80 |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
28 |
$682.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
46 |
29 |
$280.00 |
| D0330 |
Panoramic radiographic image |
42 |
42 |
$168.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
27 |
14 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
170 |
170 |
$0.00 |
| D1351 |
Sealant - per tooth |
78 |
22 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
52 |
52 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
99 |
99 |
$0.00 |
| D1999 |
|
287 |
262 |
$0.00 |
| D1120 |
Prophylaxis - child |
161 |
161 |
$0.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
62 |
21 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
25 |
25 |
$0.00 |