| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
475 |
292 |
$341.96 |
| D1120 |
Prophylaxis - child |
1,085 |
1,078 |
$116.64 |
| D1206 |
Topical application of fluoride varnish |
1,381 |
1,367 |
$96.75 |
| D1110 |
Prophylaxis - adult |
304 |
297 |
$95.12 |
| D0120 |
Periodic oral evaluation - established patient |
1,117 |
1,112 |
$78.06 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
302 |
197 |
$70.78 |
| D0274 |
Bitewings - four radiographic images |
497 |
493 |
$59.98 |
| D0220 |
Intraoral - periapical first radiographic image |
380 |
377 |
$26.04 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
130 |
125 |
$24.75 |
| D0230 |
Intraoral - periapical each additional radiographic image |
812 |
268 |
$10.70 |
| D0603 |
|
1,033 |
1,020 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
70 |
70 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
626 |
625 |
$0.00 |
| D1351 |
Sealant - per tooth |
354 |
120 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
18 |
17 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
14 |
$0.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
109 |
105 |
$0.00 |
| D0330 |
Panoramic radiographic image |
197 |
194 |
$0.00 |