| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
67 |
26 |
$7K |
| D1120 |
Prophylaxis - child |
193 |
193 |
$7K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
77 |
28 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
79 |
47 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
77 |
49 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
180 |
180 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
198 |
198 |
$4K |
| D9248 |
|
28 |
28 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
49 |
49 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
51 |
51 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
40 |
40 |
$1K |
| D0272 |
Bitewings - two radiographic images |
66 |
65 |
$1K |
| D1206 |
Topical application of fluoride varnish |
51 |
51 |
$1K |
| D1110 |
Prophylaxis - adult |
19 |
19 |
$834.60 |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$751.91 |
| D0145 |
Oral evaluation for a patient under three years of age |
29 |
29 |
$683.20 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$152.16 |