| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
743 |
741 |
$44K |
| D1110 |
Prophylaxis - adult |
230 |
230 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
120 |
76 |
$10K |
| D0330 |
Panoramic radiographic image |
120 |
120 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
160 |
158 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$341.41 |
| D1351 |
Sealant - per tooth |
170 |
37 |
$287.56 |
| D1206 |
Topical application of fluoride varnish |
844 |
842 |
$287.17 |
| D0120 |
Periodic oral evaluation - established patient |
765 |
765 |
$139.80 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
145 |
136 |
$68.00 |
| D0220 |
Intraoral - periapical first radiographic image |
715 |
705 |
$57.91 |
| D0272 |
Bitewings - two radiographic images |
411 |
410 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
218 |
217 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,120 |
635 |
$-205.46 |