| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
384 |
384 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
94 |
94 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
44 |
27 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
86 |
43 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
210 |
199 |
$2K |
| D0330 |
Panoramic radiographic image |
36 |
36 |
$950.97 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
115 |
115 |
$733.39 |
| D0120 |
Periodic oral evaluation - established patient |
192 |
192 |
$254.27 |
| D1206 |
Topical application of fluoride varnish |
114 |
114 |
$54.20 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
379 |
333 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
65 |
65 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
118 |
112 |
$0.00 |