| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
603 |
593 |
$12K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
118 |
27 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
573 |
564 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
431 |
427 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
141 |
53 |
$7K |
| D0272 |
Bitewings - two radiographic images |
241 |
237 |
$2K |
| D0240 |
|
137 |
80 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
20 |
12 |
$972.05 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
34 |
32 |
$823.45 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
13 |
$301.45 |
| D0220 |
Intraoral - periapical first radiographic image |
19 |
19 |
$95.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
15 |
15 |
$75.00 |
| D1999 |
|
99 |
92 |
$0.00 |