| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
46 |
45 |
$47.00 |
| D0120 |
Periodic oral evaluation - established patient |
1,863 |
1,814 |
$44.00 |
| D1120 |
Prophylaxis - child |
2,225 |
2,155 |
$34.00 |
| D1206 |
Topical application of fluoride varnish |
2,438 |
2,335 |
$30.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,104 |
1,738 |
$26.40 |
| D0220 |
Intraoral - periapical first radiographic image |
2,021 |
1,890 |
$23.02 |
| D0274 |
Bitewings - four radiographic images |
124 |
121 |
$22.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
304 |
258 |
$0.00 |
| D1999 |
|
182 |
143 |
$0.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
141 |
37 |
$0.00 |
| D1110 |
Prophylaxis - adult |
99 |
97 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
333 |
179 |
$0.00 |
| D0350 |
|
188 |
89 |
$0.00 |
| D0330 |
Panoramic radiographic image |
33 |
33 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
175 |
166 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
1,417 |
1,360 |
$0.00 |
| D9997 |
|
13 |
13 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
171 |
81 |
$0.00 |
| D1351 |
Sealant - per tooth |
260 |
97 |
$0.00 |
| D0603 |
|
107 |
94 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
108 |
100 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
59 |
27 |
$0.00 |
| D1330 |
|
37 |
36 |
$0.00 |