| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
119 |
119 |
$16K |
| D1120 |
Prophylaxis - child |
222 |
221 |
$14K |
| D1110 |
Prophylaxis - adult |
125 |
125 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
64 |
46 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
45 |
45 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$952.46 |
| D0120 |
Periodic oral evaluation - established patient |
321 |
320 |
$732.97 |
| D0274 |
Bitewings - four radiographic images |
77 |
77 |
$683.12 |
| D1330 |
|
348 |
347 |
$85.62 |
| D0272 |
Bitewings - two radiographic images |
107 |
106 |
$28.55 |
| D0220 |
Intraoral - periapical first radiographic image |
212 |
211 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
27 |
26 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
360 |
359 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
199 |
198 |
$0.00 |