| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,638 |
3,637 |
$286K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,981 |
421 |
$144K |
| D1110 |
Prophylaxis - adult |
688 |
687 |
$79K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
894 |
894 |
$76K |
| D0145 |
Oral evaluation for a patient under three years of age |
941 |
940 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
424 |
242 |
$27K |
| D7140 |
Extraction, erupted tooth or exposed root |
996 |
452 |
$20K |
| D1351 |
Sealant - per tooth |
3,999 |
985 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
397 |
238 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
399 |
396 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
3,584 |
3,582 |
$11K |
| D1354 |
|
587 |
164 |
$5K |
| D9420 |
|
96 |
96 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
992 |
892 |
$1K |
| D9310 |
|
12 |
12 |
$650.99 |
| D0220 |
Intraoral - periapical first radiographic image |
5,146 |
4,960 |
$426.70 |
| D2332 |
|
22 |
12 |
$234.80 |
| D0274 |
Bitewings - four radiographic images |
653 |
652 |
$156.48 |
| D0272 |
Bitewings - two radiographic images |
2,571 |
2,569 |
$140.86 |
| D1206 |
Topical application of fluoride varnish |
5,080 |
5,078 |
$40.65 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
65 |
38 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,858 |
4,682 |
$-12.71 |