| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,097 |
1,807 |
$328.00 |
| D1120 |
Prophylaxis - child |
6,375 |
6,260 |
$228.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
8,558 |
8,374 |
$108.00 |
| D0210 |
Intraoral - complete series of radiographic images |
217 |
215 |
$106.87 |
| D0120 |
Periodic oral evaluation - established patient |
7,753 |
7,591 |
$104.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,663 |
1,581 |
$62.00 |
| D0272 |
Bitewings - two radiographic images |
4,468 |
4,373 |
$36.00 |
| D0220 |
Intraoral - periapical first radiographic image |
6,574 |
6,307 |
$30.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
339 |
331 |
$29.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,557 |
5,658 |
$10.00 |
| D1206 |
Topical application of fluoride varnish |
243 |
238 |
$0.00 |
| D1351 |
Sealant - per tooth |
1,698 |
579 |
$0.00 |
| D9248 |
|
191 |
180 |
$0.00 |
| D0240 |
|
214 |
130 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
410 |
214 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
380 |
328 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
31 |
15 |
$0.00 |
| D1110 |
Prophylaxis - adult |
2,048 |
1,995 |
$0.00 |
| D0330 |
Panoramic radiographic image |
748 |
726 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
2,140 |
2,085 |
$0.00 |
| D1999 |
|
5,067 |
4,397 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
431 |
272 |
$0.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
105 |
38 |
$0.00 |