| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
401 |
205 |
$430.28 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
266 |
152 |
$412.16 |
| D1120 |
Prophylaxis - child |
819 |
782 |
$142.00 |
| D0120 |
Periodic oral evaluation - established patient |
912 |
876 |
$92.10 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
229 |
197 |
$86.12 |
| D1351 |
Sealant - per tooth |
22 |
12 |
$69.69 |
| D0272 |
Bitewings - two radiographic images |
531 |
501 |
$69.24 |
| D1208 |
Topical application of fluoride, excluding varnish |
777 |
729 |
$64.20 |
| D0220 |
Intraoral - periapical first radiographic image |
1,014 |
963 |
$55.72 |
| D0230 |
Intraoral - periapical each additional radiographic image |
942 |
894 |
$30.66 |
| D0274 |
Bitewings - four radiographic images |
237 |
227 |
$0.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
38 |
12 |
$0.00 |
| D1110 |
Prophylaxis - adult |
176 |
167 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
69 |
58 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
249 |
249 |
$0.00 |