| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,130 |
3,128 |
$252K |
| D0274 |
Bitewings - four radiographic images |
1,078 |
1,077 |
$72K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
900 |
529 |
$63K |
| D1110 |
Prophylaxis - adult |
1,047 |
1,046 |
$53K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
702 |
702 |
$28K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
522 |
339 |
$20K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
332 |
96 |
$19K |
| D9420 |
|
19 |
19 |
$17K |
| D1351 |
Sealant - per tooth |
2,853 |
641 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
55 |
55 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
152 |
91 |
$7K |
| D0330 |
Panoramic radiographic image |
112 |
112 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
74 |
74 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
3,350 |
3,348 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
42 |
41 |
$1K |
| D9248 |
|
13 |
13 |
$302.73 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,222 |
1,182 |
$271.65 |
| D1206 |
Topical application of fluoride varnish |
1,525 |
1,525 |
$212.33 |
| D0220 |
Intraoral - periapical first radiographic image |
4,597 |
4,568 |
$114.20 |
| D1208 |
Topical application of fluoride, excluding varnish |
2,915 |
2,912 |
$108.73 |
| D0272 |
Bitewings - two radiographic images |
2,017 |
2,014 |
$33.28 |
| D1330 |
|
876 |
876 |
$0.00 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
24 |
13 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,469 |
4,312 |
$-45.58 |