| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
37 |
27 |
$110.00 |
| D1120 |
Prophylaxis - child |
779 |
743 |
$40.00 |
| D0120 |
Periodic oral evaluation - established patient |
724 |
687 |
$32.00 |
| D0272 |
Bitewings - two radiographic images |
595 |
557 |
$23.00 |
| D0220 |
Intraoral - periapical first radiographic image |
800 |
736 |
$20.00 |
| D1206 |
Topical application of fluoride varnish |
902 |
860 |
$19.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
757 |
677 |
$10.00 |
| D1110 |
Prophylaxis - adult |
210 |
202 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
34 |
25 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
13 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13 |
13 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
463 |
213 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
246 |
234 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
198 |
192 |
$0.00 |