| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
347 |
347 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
243 |
137 |
$17K |
| D0330 |
Panoramic radiographic image |
226 |
226 |
$17K |
| D1330 |
|
595 |
594 |
$9K |
| D0274 |
Bitewings - four radiographic images |
604 |
603 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
26 |
13 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
59 |
32 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
206 |
206 |
$1K |
| D9999 |
Unspecified adjunctive procedure, by report |
54 |
54 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
411 |
410 |
$280.93 |
| D1120 |
Prophylaxis - child |
257 |
256 |
$206.64 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
140 |
132 |
$163.15 |
| D0220 |
Intraoral - periapical first radiographic image |
663 |
659 |
$62.46 |
| D0230 |
Intraoral - periapical each additional radiographic image |
665 |
633 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
575 |
574 |
$0.00 |
| D1351 |
Sealant - per tooth |
48 |
12 |
$0.00 |