| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
210 |
210 |
$18K |
| D1120 |
Prophylaxis - child |
85 |
85 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
93 |
57 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
55 |
54 |
$936.55 |
| D0274 |
Bitewings - four radiographic images |
163 |
163 |
$162.17 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
71 |
68 |
$33.68 |
| D1206 |
Topical application of fluoride varnish |
163 |
163 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
245 |
245 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
267 |
266 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
73 |
73 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
373 |
366 |
$0.00 |