| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,064 |
4,049 |
$276K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,006 |
368 |
$75K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
979 |
975 |
$64K |
| D1110 |
Prophylaxis - adult |
641 |
639 |
$62K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,067 |
587 |
$62K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
721 |
429 |
$23K |
| D0330 |
Panoramic radiographic image |
242 |
240 |
$15K |
| D0145 |
Oral evaluation for a patient under three years of age |
233 |
233 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
78 |
78 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
403 |
197 |
$13K |
| D9420 |
|
29 |
28 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
415 |
399 |
$11K |
| D0274 |
Bitewings - four radiographic images |
640 |
638 |
$3K |
| D1206 |
Topical application of fluoride varnish |
4,485 |
4,471 |
$1K |
| D1351 |
Sealant - per tooth |
1,641 |
366 |
$1K |
| D9248 |
|
17 |
16 |
$794.03 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
522 |
487 |
$431.16 |
| D7111 |
|
17 |
12 |
$320.71 |
| D0220 |
Intraoral - periapical first radiographic image |
4,041 |
3,962 |
$185.33 |
| D0120 |
Periodic oral evaluation - established patient |
3,453 |
3,439 |
$118.10 |
| D0272 |
Bitewings - two radiographic images |
982 |
976 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12,534 |
3,741 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$0.00 |
| D1330 |
|
364 |
364 |
$0.00 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
31 |
12 |
$0.00 |
| D9986 |
|
14 |
14 |
$0.00 |