| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,746 |
2,746 |
$0.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
725 |
408 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
1,626 |
1,626 |
$0.00 |
| D0330 |
Panoramic radiographic image |
329 |
329 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
332 |
332 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,720 |
1,699 |
$0.00 |
| D1120 |
Prophylaxis - child |
5,315 |
5,315 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
797 |
575 |
$0.00 |
| D0270 |
|
109 |
109 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,559 |
903 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
859 |
495 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
8,176 |
8,176 |
$0.00 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
723 |
408 |
$0.00 |
| D9248 |
|
410 |
410 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
227 |
160 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
917 |
890 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
873 |
873 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
2,070 |
2,070 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
7,530 |
7,530 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
306 |
305 |
$0.00 |
| D9630 |
|
199 |
199 |
$0.00 |
| D1351 |
Sealant - per tooth |
2,156 |
573 |
$0.00 |
| D3120 |
|
28 |
25 |
$0.00 |
| D0240 |
|
29 |
28 |
$0.00 |