| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
626 |
623 |
$66K |
| D1351 |
Sealant - per tooth |
376 |
104 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
279 |
135 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
770 |
759 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
91 |
90 |
$10K |
| D0330 |
Panoramic radiographic image |
41 |
41 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
171 |
82 |
$7K |
| D2335 |
|
38 |
14 |
$3K |
| D1354 |
|
231 |
57 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
61 |
56 |
$2K |
| D1999 |
|
31 |
30 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
62 |
39 |
$628.30 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
13 |
$591.58 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
73 |
65 |
$41.00 |
| D1120 |
Prophylaxis - child |
545 |
542 |
$23.81 |
| D0230 |
Intraoral - periapical each additional radiographic image |
888 |
714 |
$17.00 |
| D1330 |
|
729 |
725 |
$3.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
723 |
719 |
$0.00 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
25 |
15 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
321 |
319 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
37 |
24 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
287 |
285 |
$0.00 |
| D1110 |
Prophylaxis - adult |
168 |
167 |
$0.00 |