| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
587 |
580 |
$34.00 |
| D0120 |
Periodic oral evaluation - established patient |
744 |
732 |
$22.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
821 |
811 |
$15.00 |
| D0272 |
Bitewings - two radiographic images |
331 |
326 |
$14.00 |
| D0220 |
Intraoral - periapical first radiographic image |
296 |
283 |
$10.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
143 |
139 |
$5.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
183 |
164 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
332 |
327 |
$0.00 |
| D1110 |
Prophylaxis - adult |
242 |
237 |
$0.00 |
| D0330 |
Panoramic radiographic image |
144 |
141 |
$0.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
36 |
24 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
168 |
120 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
116 |
109 |
$0.00 |
| D1351 |
Sealant - per tooth |
155 |
53 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
69 |
69 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
143 |
111 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
622 |
370 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
130 |
130 |
$0.00 |