| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
189 |
189 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
282 |
133 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
99 |
99 |
$11K |
| D1110 |
Prophylaxis - adult |
125 |
125 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
357 |
355 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
92 |
44 |
$2K |
| D1351 |
Sealant - per tooth |
174 |
40 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$692.17 |
| D0330 |
Panoramic radiographic image |
46 |
46 |
$465.15 |
| D0220 |
Intraoral - periapical first radiographic image |
381 |
363 |
$313.35 |
| D1206 |
Topical application of fluoride varnish |
227 |
227 |
$80.58 |
| D0274 |
Bitewings - four radiographic images |
74 |
74 |
$56.59 |
| D0120 |
Periodic oral evaluation - established patient |
80 |
80 |
$52.11 |
| D0230 |
Intraoral - periapical each additional radiographic image |
367 |
206 |
$33.28 |
| D0272 |
Bitewings - two radiographic images |
191 |
191 |
$19.66 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
32 |
29 |
$0.00 |