| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
854 |
852 |
$53K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
90 |
55 |
$6K |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$1K |
| D1120 |
Prophylaxis - child |
24 |
24 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
41 |
36 |
$850.61 |
| D0274 |
Bitewings - four radiographic images |
151 |
151 |
$244.62 |
| D0120 |
Periodic oral evaluation - established patient |
686 |
682 |
$222.41 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
364 |
325 |
$100.15 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
17 |
17 |
$86.49 |
| D0220 |
Intraoral - periapical first radiographic image |
152 |
146 |
$17.41 |
| D0230 |
Intraoral - periapical each additional radiographic image |
17 |
13 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
251 |
249 |
$-154.20 |