| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,013 |
953 |
$136.00 |
| D0210 |
Intraoral - complete series of radiographic images |
200 |
200 |
$94.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
241 |
230 |
$84.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
1,066 |
996 |
$75.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
415 |
264 |
$64.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
295 |
180 |
$56.00 |
| D0120 |
Periodic oral evaluation - established patient |
1,149 |
1,073 |
$44.00 |
| D1110 |
Prophylaxis - adult |
386 |
359 |
$42.00 |
| D1351 |
Sealant - per tooth |
500 |
160 |
$42.00 |
| D0220 |
Intraoral - periapical first radiographic image |
553 |
506 |
$30.00 |
| D0274 |
Bitewings - four radiographic images |
419 |
391 |
$22.00 |
| D0140 |
Limited oral evaluation - problem focused |
67 |
52 |
$22.00 |
| D0272 |
Bitewings - two radiographic images |
584 |
546 |
$14.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
377 |
323 |
$10.00 |
| D0330 |
Panoramic radiographic image |
263 |
252 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
250 |
206 |
$0.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
18 |
12 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
322 |
305 |
$0.00 |