| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
761 |
761 |
$6K |
| D1120 |
Prophylaxis - child |
330 |
330 |
$5K |
| D1110 |
Prophylaxis - adult |
386 |
386 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
670 |
661 |
$3K |
| D0274 |
Bitewings - four radiographic images |
414 |
414 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
321 |
321 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
112 |
96 |
$2K |
| D0272 |
Bitewings - two radiographic images |
189 |
189 |
$860.39 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
40 |
35 |
$743.46 |
| D0330 |
Panoramic radiographic image |
74 |
74 |
$467.59 |
| D0140 |
Limited oral evaluation - problem focused |
67 |
67 |
$241.71 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$234.19 |
| D1351 |
Sealant - per tooth |
31 |
12 |
$163.36 |
| D0270 |
|
16 |
15 |
$67.26 |
| D1330 |
|
300 |
300 |
$0.00 |
| D9630 |
|
12 |
12 |
$0.00 |
| D9215 |
|
13 |
13 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
65 |
65 |
$0.00 |