| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
130 |
126 |
$142.68 |
| D0330 |
Panoramic radiographic image |
95 |
93 |
$108.32 |
| D1208 |
Topical application of fluoride, excluding varnish |
245 |
239 |
$54.93 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
33 |
33 |
$40.49 |
| D0274 |
Bitewings - four radiographic images |
128 |
123 |
$29.99 |
| D0230 |
Intraoral - periapical each additional radiographic image |
82 |
57 |
$15.00 |
| D0220 |
Intraoral - periapical first radiographic image |
261 |
240 |
$13.02 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
91 |
39 |
$0.00 |
| D1120 |
Prophylaxis - child |
213 |
208 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
12 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
196 |
181 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
348 |
335 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
67 |
66 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
68 |
33 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
69 |
28 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
18 |
18 |
$0.00 |