| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
231 |
215 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
362 |
340 |
$5K |
| D0274 |
Bitewings - four radiographic images |
163 |
150 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
216 |
200 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
100 |
83 |
$588.05 |
| D0220 |
Intraoral - periapical first radiographic image |
65 |
54 |
$541.99 |
| D0230 |
Intraoral - periapical each additional radiographic image |
65 |
54 |
$409.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
14 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
14 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
59 |
13 |
$0.00 |