| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
327 |
168 |
$390.00 |
| D1120 |
Prophylaxis - child |
6,233 |
5,941 |
$232.09 |
| D0120 |
Periodic oral evaluation - established patient |
6,708 |
6,377 |
$189.62 |
| D1110 |
Prophylaxis - adult |
1,603 |
1,519 |
$139.94 |
| D1208 |
Topical application of fluoride, excluding varnish |
4,541 |
4,236 |
$133.08 |
| D0272 |
Bitewings - two radiographic images |
4,266 |
4,073 |
$114.19 |
| D1351 |
Sealant - per tooth |
3,832 |
1,062 |
$73.96 |
| D0330 |
Panoramic radiographic image |
587 |
561 |
$51.30 |
| D0220 |
Intraoral - periapical first radiographic image |
5,972 |
5,671 |
$47.83 |
| D0230 |
Intraoral - periapical each additional radiographic image |
11,662 |
5,418 |
$38.17 |
| D1206 |
Topical application of fluoride varnish |
2,795 |
2,735 |
$32.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
933 |
867 |
$28.00 |
| D1330 |
|
6,111 |
5,516 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
360 |
349 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$0.00 |
| D9248 |
|
13 |
13 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
554 |
517 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
141 |
95 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
757 |
732 |
$0.00 |
| D1354 |
|
60 |
24 |
$0.00 |