| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
727 |
725 |
$58K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
170 |
107 |
$14K |
| D1351 |
Sealant - per tooth |
282 |
95 |
$13K |
| D5110 |
|
35 |
30 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
128 |
126 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
111 |
73 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
40 |
30 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
255 |
251 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
131 |
16 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
80 |
13 |
$3K |
| D7111 |
|
41 |
28 |
$2K |
| D1999 |
|
30 |
30 |
$1K |
| D0330 |
Panoramic radiographic image |
170 |
167 |
$813.00 |
| D0220 |
Intraoral - periapical first radiographic image |
1,000 |
995 |
$208.42 |
| D0274 |
Bitewings - four radiographic images |
165 |
164 |
$160.00 |
| D1120 |
Prophylaxis - child |
597 |
596 |
$85.00 |
| D0272 |
Bitewings - two radiographic images |
437 |
436 |
$83.00 |
| D1110 |
Prophylaxis - adult |
163 |
162 |
$45.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
39 |
29 |
$0.00 |
| D1330 |
|
900 |
898 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
819 |
817 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,520 |
894 |
$0.00 |