| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
482 |
482 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
549 |
547 |
$18K |
| D0330 |
Panoramic radiographic image |
198 |
198 |
$17K |
| D1120 |
Prophylaxis - child |
508 |
508 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
270 |
270 |
$7K |
| D1206 |
Topical application of fluoride varnish |
1,149 |
1,143 |
$5K |
| D1351 |
Sealant - per tooth |
213 |
57 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
56 |
25 |
$3K |
| D0350 |
|
933 |
932 |
$3K |
| D0274 |
Bitewings - four radiographic images |
400 |
400 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
362 |
360 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
40 |
26 |
$1K |
| D9996 |
|
274 |
274 |
$980.00 |
| D0191 |
|
124 |
120 |
$460.64 |
| D0220 |
Intraoral - periapical first radiographic image |
731 |
730 |
$398.34 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,760 |
671 |
$240.00 |
| D0272 |
Bitewings - two radiographic images |
143 |
143 |
$13.00 |
| D1330 |
|
1,170 |
1,167 |
$3.00 |
| D1310 |
|
164 |
164 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
29 |
29 |
$0.00 |