| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,179 |
1,169 |
$88K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
573 |
349 |
$38K |
| D1351 |
Sealant - per tooth |
700 |
244 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
245 |
237 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
208 |
134 |
$10K |
| D1120 |
Prophylaxis - child |
958 |
944 |
$7K |
| D7111 |
|
128 |
83 |
$7K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
34 |
28 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
325 |
306 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
34 |
30 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,941 |
1,448 |
$2K |
| D1110 |
Prophylaxis - adult |
483 |
478 |
$2K |
| D0274 |
Bitewings - four radiographic images |
463 |
458 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
51 |
51 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
1,644 |
1,608 |
$684.43 |
| D1999 |
|
15 |
15 |
$600.00 |
| D1330 |
|
1,531 |
1,511 |
$575.03 |
| D3120 |
|
65 |
48 |
$335.76 |
| D1208 |
Topical application of fluoride, excluding varnish |
1,453 |
1,433 |
$306.90 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
33 |
27 |
$150.00 |
| D0272 |
Bitewings - two radiographic images |
647 |
636 |
$128.00 |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
16 |
$0.00 |
| D0330 |
Panoramic radiographic image |
264 |
255 |
$0.00 |