| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,393 |
915 |
$192.00 |
| D0220 |
Intraoral - periapical first radiographic image |
3,048 |
2,690 |
$58.20 |
| D1120 |
Prophylaxis - child |
2,166 |
1,978 |
$34.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
508 |
443 |
$29.00 |
| D0120 |
Periodic oral evaluation - established patient |
2,682 |
2,421 |
$22.00 |
| D1206 |
Topical application of fluoride varnish |
2,751 |
2,481 |
$15.00 |
| D0272 |
Bitewings - two radiographic images |
1,159 |
1,058 |
$14.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,208 |
2,086 |
$5.00 |
| D0274 |
Bitewings - four radiographic images |
1,370 |
1,223 |
$0.00 |
| D1110 |
Prophylaxis - adult |
709 |
636 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
994 |
520 |
$0.00 |
| D0330 |
Panoramic radiographic image |
117 |
109 |
$0.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
66 |
28 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
450 |
354 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
335 |
217 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
209 |
184 |
$0.00 |
| D1351 |
Sealant - per tooth |
1,068 |
400 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
250 |
234 |
$0.00 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
194 |
69 |
$0.00 |
| D9248 |
|
29 |
26 |
$0.00 |
| D2330 |
|
18 |
13 |
$0.00 |