| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
986 |
974 |
$65K |
| D1351 |
Sealant - per tooth |
778 |
277 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
301 |
196 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
264 |
178 |
$13K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
72 |
63 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
152 |
152 |
$6K |
| D7111 |
|
116 |
81 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
378 |
366 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,354 |
1,120 |
$3K |
| D1330 |
|
1,245 |
1,231 |
$661.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
74 |
64 |
$571.76 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$432.54 |
| D0220 |
Intraoral - periapical first radiographic image |
1,329 |
1,306 |
$365.03 |
| D1110 |
Prophylaxis - adult |
346 |
342 |
$298.78 |
| D0272 |
Bitewings - two radiographic images |
610 |
599 |
$163.14 |
| D1120 |
Prophylaxis - child |
810 |
800 |
$127.32 |
| D0274 |
Bitewings - four radiographic images |
301 |
298 |
$72.45 |
| D1208 |
Topical application of fluoride, excluding varnish |
1,199 |
1,185 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$0.00 |
| D0330 |
Panoramic radiographic image |
171 |
171 |
$0.00 |