| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,825 |
6,822 |
$412K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,657 |
889 |
$87K |
| D1110 |
Prophylaxis - adult |
936 |
936 |
$80K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
468 |
467 |
$22K |
| D0330 |
Panoramic radiographic image |
204 |
204 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
7,599 |
7,598 |
$12K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
191 |
84 |
$11K |
| D9420 |
|
82 |
82 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
209 |
122 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
133 |
130 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
116 |
68 |
$2K |
| D1351 |
Sealant - per tooth |
1,858 |
445 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
38 |
37 |
$984.02 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,752 |
1,586 |
$394.78 |
| D0220 |
Intraoral - periapical first radiographic image |
1,358 |
1,330 |
$56.61 |
| D0272 |
Bitewings - two radiographic images |
3,161 |
3,158 |
$31.74 |
| D1206 |
Topical application of fluoride varnish |
6,686 |
6,683 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
623 |
482 |
$0.00 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
85 |
40 |
$0.00 |