| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,474 |
2,473 |
$194K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
515 |
338 |
$39K |
| D1110 |
Prophylaxis - adult |
651 |
651 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
239 |
239 |
$22K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
125 |
98 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,783 |
2,579 |
$9K |
| D1351 |
Sealant - per tooth |
2,030 |
649 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
76 |
53 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
104 |
84 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
13 |
$2K |
| D1120 |
Prophylaxis - child |
2,072 |
2,070 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
409 |
384 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
66 |
66 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,758 |
2,755 |
$475.80 |
| D0220 |
Intraoral - periapical first radiographic image |
2,673 |
2,662 |
$339.04 |
| D0272 |
Bitewings - two radiographic images |
2,113 |
2,110 |
$308.33 |
| D1330 |
|
2,765 |
2,762 |
$259.76 |