| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
213 |
132 |
$56.00 |
| D0330 |
Panoramic radiographic image |
354 |
301 |
$39.00 |
| D0120 |
Periodic oral evaluation - established patient |
1,275 |
1,110 |
$22.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
607 |
306 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
1,215 |
1,021 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
571 |
494 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
318 |
316 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
262 |
166 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
368 |
305 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
92 |
92 |
$0.00 |
| D1351 |
Sealant - per tooth |
401 |
153 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
221 |
221 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
82 |
41 |
$0.00 |
| D1110 |
Prophylaxis - adult |
402 |
348 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
507 |
419 |
$0.00 |
| D1120 |
Prophylaxis - child |
1,142 |
997 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
598 |
485 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
300 |
195 |
$0.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
22 |
16 |
$0.00 |