| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
296 |
291 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
569 |
561 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
12 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
12 |
$462.42 |
| D0230 |
Intraoral - periapical each additional radiographic image |
587 |
574 |
$292.10 |
| D1120 |
Prophylaxis - child |
275 |
269 |
$265.86 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
48 |
43 |
$205.12 |
| D0220 |
Intraoral - periapical first radiographic image |
639 |
623 |
$184.73 |
| D1351 |
Sealant - per tooth |
194 |
65 |
$116.28 |
| D1206 |
Topical application of fluoride varnish |
664 |
655 |
$81.00 |
| D0274 |
Bitewings - four radiographic images |
308 |
302 |
$55.77 |
| D0272 |
Bitewings - two radiographic images |
152 |
147 |
$0.00 |
| D1330 |
|
677 |
668 |
$0.00 |