| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
553 |
549 |
$39K |
| D9248 |
|
394 |
387 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
266 |
141 |
$22K |
| D1351 |
Sealant - per tooth |
335 |
121 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
273 |
273 |
$19K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
347 |
159 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
364 |
155 |
$10K |
| D3120 |
|
131 |
95 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
63 |
43 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
17 |
15 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
86 |
50 |
$5K |
| D0272 |
Bitewings - two radiographic images |
591 |
590 |
$4K |
| D1330 |
|
823 |
820 |
$3K |
| D1120 |
Prophylaxis - child |
601 |
598 |
$3K |
| D9920 |
|
144 |
144 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
163 |
162 |
$2K |
| D1510 |
|
28 |
21 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
831 |
828 |
$2K |
| D0330 |
Panoramic radiographic image |
125 |
125 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
44 |
44 |
$1K |
| D0274 |
Bitewings - four radiographic images |
154 |
153 |
$722.32 |
| D0240 |
|
306 |
244 |
$691.74 |
| D1110 |
Prophylaxis - adult |
164 |
163 |
$276.63 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
13 |
$198.65 |
| D0230 |
Intraoral - periapical each additional radiographic image |
63 |
43 |
$130.56 |