| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
190 |
190 |
$5K |
| D1120 |
Prophylaxis - child |
123 |
123 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
38 |
21 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
54 |
54 |
$4K |
| D1110 |
Prophylaxis - adult |
66 |
66 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
197 |
197 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
21 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
17 |
17 |
$2K |
| D0272 |
Bitewings - two radiographic images |
115 |
115 |
$2K |
| D1351 |
Sealant - per tooth |
61 |
17 |
$2K |
| D0274 |
Bitewings - four radiographic images |
75 |
75 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
38 |
38 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
80 |
79 |
$942.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
47 |
43 |
$494.93 |
| D0330 |
Panoramic radiographic image |
54 |
54 |
$0.00 |
| D0603 |
|
264 |
261 |
$0.00 |