| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
245 |
239 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
69 |
69 |
$7K |
| D1351 |
Sealant - per tooth |
219 |
59 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
18 |
$1K |
| D0274 |
Bitewings - four radiographic images |
59 |
58 |
$270.57 |
| D0272 |
Bitewings - two radiographic images |
183 |
179 |
$26.76 |
| D1330 |
|
307 |
301 |
$3.00 |
| D0220 |
Intraoral - periapical first radiographic image |
60 |
59 |
$0.00 |
| D1120 |
Prophylaxis - child |
265 |
259 |
$0.00 |
| D1110 |
Prophylaxis - adult |
46 |
46 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
17 |
17 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
265 |
259 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
46 |
46 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
33 |
33 |
$0.00 |