| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,223 |
1,158 |
$34.00 |
| D1206 |
Topical application of fluoride varnish |
1,337 |
1,232 |
$30.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
304 |
274 |
$28.00 |
| D0120 |
Periodic oral evaluation - established patient |
1,054 |
962 |
$22.00 |
| D0272 |
Bitewings - two radiographic images |
959 |
876 |
$14.00 |
| D0210 |
Intraoral - complete series of radiographic images |
55 |
55 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
871 |
439 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
231 |
110 |
$0.00 |
| D1330 |
|
1,447 |
1,275 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
12 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
32 |
14 |
$0.00 |
| D1351 |
Sealant - per tooth |
207 |
47 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
616 |
550 |
$0.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
28 |
13 |
$0.00 |
| D1110 |
Prophylaxis - adult |
202 |
185 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
73 |
59 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
292 |
253 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
15 |
$0.00 |
| D0330 |
Panoramic radiographic image |
67 |
53 |
$0.00 |
| D0350 |
|
138 |
22 |
$0.00 |