| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
877 |
875 |
$52K |
| D0210 |
Intraoral - complete series of radiographic images |
421 |
420 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
202 |
129 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
762 |
760 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
171 |
171 |
$4K |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$1K |
| D0274 |
Bitewings - four radiographic images |
361 |
359 |
$400.44 |
| D0120 |
Periodic oral evaluation - established patient |
401 |
400 |
$165.88 |
| D0220 |
Intraoral - periapical first radiographic image |
563 |
555 |
$44.40 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
96 |
89 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
168 |
168 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
595 |
316 |
$-100.05 |