| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
200 |
189 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
272 |
259 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
282 |
191 |
$17K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
103 |
80 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
224 |
211 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
61 |
46 |
$2K |
| D1120 |
Prophylaxis - child |
284 |
261 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
32 |
28 |
$399.55 |
| D1351 |
Sealant - per tooth |
279 |
77 |
$351.65 |
| D0230 |
Intraoral - periapical each additional radiographic image |
624 |
465 |
$187.28 |
| D0272 |
Bitewings - two radiographic images |
212 |
192 |
$45.78 |
| D0220 |
Intraoral - periapical first radiographic image |
554 |
514 |
$14.57 |
| D1206 |
Topical application of fluoride varnish |
483 |
449 |
$0.00 |
| D1330 |
|
480 |
447 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
218 |
207 |
$0.00 |