| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
478 |
235 |
$237.05 |
| D1110 |
Prophylaxis - adult |
260 |
256 |
$122.02 |
| D0120 |
Periodic oral evaluation - established patient |
710 |
699 |
$91.33 |
| D1208 |
Topical application of fluoride, excluding varnish |
625 |
617 |
$91.32 |
| D1120 |
Prophylaxis - child |
600 |
583 |
$89.70 |
| D0274 |
Bitewings - four radiographic images |
397 |
390 |
$71.56 |
| D0272 |
Bitewings - two radiographic images |
404 |
388 |
$20.39 |
| D1206 |
Topical application of fluoride varnish |
219 |
207 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
174 |
164 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
218 |
200 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
22 |
14 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
546 |
207 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
454 |
236 |
$0.00 |
| D1351 |
Sealant - per tooth |
41 |
12 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
21 |
21 |
$0.00 |
| D0330 |
Panoramic radiographic image |
40 |
40 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
414 |
385 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
87 |
78 |
$0.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
33 |
31 |
$0.00 |