| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
393 |
393 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
103 |
103 |
$1K |
| D1206 |
Topical application of fluoride varnish |
571 |
569 |
$864.96 |
| D0272 |
Bitewings - two radiographic images |
171 |
171 |
$439.84 |
| D0220 |
Intraoral - periapical first radiographic image |
149 |
148 |
$208.30 |
| D0140 |
Limited oral evaluation - problem focused |
24 |
24 |
$53.14 |
| D0230 |
Intraoral - periapical each additional radiographic image |
57 |
53 |
$49.56 |
| D0120 |
Periodic oral evaluation - established patient |
312 |
312 |
$0.00 |
| D1351 |
Sealant - per tooth |
285 |
79 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
137 |
77 |
$0.00 |
| D0603 |
|
18 |
18 |
$0.00 |
| D1110 |
Prophylaxis - adult |
75 |
75 |
$0.00 |
| D1354 |
|
45 |
26 |
$0.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
44 |
44 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
87 |
87 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
117 |
115 |
$0.00 |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
135 |
82 |
$0.00 |