| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
308 |
115 |
$84.00 |
| D1120 |
Prophylaxis - child |
2,745 |
2,728 |
$68.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,189 |
698 |
$64.00 |
| D0120 |
Periodic oral evaluation - established patient |
3,028 |
3,012 |
$22.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
2,963 |
2,945 |
$15.00 |
| D0272 |
Bitewings - two radiographic images |
2,104 |
2,079 |
$14.00 |
| D0220 |
Intraoral - periapical first radiographic image |
3,514 |
3,462 |
$10.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,281 |
3,203 |
$5.00 |
| D0603 |
|
123 |
121 |
$0.00 |
| D0601 |
|
14 |
13 |
$0.00 |
| D0602 |
|
116 |
111 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
73 |
72 |
$0.00 |
| D9248 |
|
286 |
279 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
204 |
204 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
87 |
86 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
102 |
71 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
599 |
589 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
535 |
509 |
$0.00 |
| D1999 |
|
123 |
120 |
$0.00 |
| D1110 |
Prophylaxis - adult |
376 |
373 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
295 |
224 |
$0.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
37 |
37 |
$0.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
127 |
84 |
$0.00 |
| D0330 |
Panoramic radiographic image |
64 |
64 |
$0.00 |