| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,745 |
3,640 |
$992.70 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
809 |
340 |
$850.58 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
675 |
648 |
$533.60 |
| D0120 |
Periodic oral evaluation - established patient |
3,394 |
3,263 |
$380.20 |
| D1208 |
Topical application of fluoride, excluding varnish |
880 |
842 |
$346.40 |
| D0274 |
Bitewings - four radiographic images |
1,105 |
1,033 |
$305.99 |
| D0220 |
Intraoral - periapical first radiographic image |
3,417 |
3,251 |
$297.86 |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,145 |
3,061 |
$293.18 |
| D1206 |
Topical application of fluoride varnish |
3,274 |
3,157 |
$138.10 |
| D0210 |
Intraoral - complete series of radiographic images |
342 |
323 |
$50.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
482 |
425 |
$29.00 |
| D1351 |
Sealant - per tooth |
464 |
161 |
$22.00 |
| D0272 |
Bitewings - two radiographic images |
662 |
636 |
$18.82 |
| D1330 |
|
3,735 |
3,470 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
30 |
28 |
$0.00 |
| D0350 |
|
2,272 |
556 |
$0.00 |
| D0330 |
Panoramic radiographic image |
235 |
222 |
$0.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
93 |
24 |
$0.00 |
| D1110 |
Prophylaxis - adult |
261 |
245 |
$0.00 |