| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
257 |
248 |
$11K |
| D1206 |
Topical application of fluoride varnish |
300 |
290 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
232 |
223 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
58 |
38 |
$4K |
| D0274 |
Bitewings - four radiographic images |
95 |
94 |
$2K |
| D1351 |
Sealant - per tooth |
66 |
17 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
184 |
177 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
45 |
44 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
109 |
57 |
$946.20 |
| D0330 |
Panoramic radiographic image |
23 |
23 |
$786.95 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
18 |
18 |
$552.78 |
| D0140 |
Limited oral evaluation - problem focused |
17 |
17 |
$268.40 |
| D9986 |
|
59 |
58 |
$0.00 |