| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
107 |
107 |
$10K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
51 |
27 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
148 |
148 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
109 |
108 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$563.87 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$276.16 |
| D0220 |
Intraoral - periapical first radiographic image |
242 |
237 |
$132.10 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
74 |
65 |
$24.46 |
| D0230 |
Intraoral - periapical each additional radiographic image |
168 |
153 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
150 |
150 |
$0.00 |