| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
620 |
521 |
$4K |
| D0160 |
|
40 |
40 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
508 |
472 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
854 |
774 |
$2K |
| D1110 |
Prophylaxis - adult |
273 |
220 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
177 |
120 |
$808.00 |
| D0274 |
Bitewings - four radiographic images |
79 |
57 |
$203.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
62 |
52 |
$105.00 |
| D1999 |
|
558 |
362 |
$0.00 |
| D0330 |
Panoramic radiographic image |
18 |
18 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
41 |
23 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
12 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
59 |
42 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
411 |
307 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
57 |
37 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
26 |
13 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
66 |
37 |
$0.00 |