| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,931 |
5,931 |
$233K |
| D0120 |
Periodic oral evaluation - established patient |
5,609 |
5,609 |
$174K |
| D1206 |
Topical application of fluoride varnish |
6,161 |
6,160 |
$159K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
905 |
472 |
$107K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
463 |
225 |
$81K |
| D0272 |
Bitewings - two radiographic images |
2,159 |
2,156 |
$51K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
672 |
672 |
$36K |
| D0220 |
Intraoral - periapical first radiographic image |
1,894 |
1,873 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,272 |
1,022 |
$29K |
| D1110 |
Prophylaxis - adult |
376 |
376 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
303 |
298 |
$16K |
| D0274 |
Bitewings - four radiographic images |
278 |
278 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
111 |
74 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
75 |
58 |
$6K |
| D1351 |
Sealant - per tooth |
94 |
36 |
$3K |
| D0330 |
Panoramic radiographic image |
41 |
41 |
$3K |
| D0240 |
|
115 |
63 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
16 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
27 |
27 |
$879.80 |
| D9248 |
|
13 |
12 |
$472.69 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
106 |
104 |
$0.00 |