| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,818 |
5,793 |
$646.40 |
| D0120 |
Periodic oral evaluation - established patient |
5,673 |
5,649 |
$611.63 |
| D1206 |
Topical application of fluoride varnish |
7,053 |
7,019 |
$428.79 |
| D0274 |
Bitewings - four radiographic images |
2,308 |
2,293 |
$404.59 |
| D1110 |
Prophylaxis - adult |
1,241 |
1,234 |
$84.00 |
| D0210 |
Intraoral - complete series of radiographic images |
358 |
356 |
$47.00 |
| D0220 |
Intraoral - periapical first radiographic image |
2,319 |
2,293 |
$20.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,461 |
1,650 |
$10.00 |
| D0330 |
Panoramic radiographic image |
963 |
956 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
691 |
669 |
$0.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
516 |
176 |
$0.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
440 |
439 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
598 |
399 |
$0.00 |
| D0603 |
|
2,745 |
2,706 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,477 |
854 |
$0.00 |
| D1351 |
Sealant - per tooth |
2,752 |
843 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
3,425 |
3,400 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
730 |
728 |
$0.00 |
| D9248 |
|
115 |
110 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
46 |
27 |
$0.00 |
| D0602 |
|
30 |
29 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
32 |
27 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
35 |
35 |
$0.00 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
44 |
12 |
$0.00 |