| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9920 |
|
228 |
204 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
300 |
110 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
332 |
331 |
$3K |
| D1120 |
Prophylaxis - child |
494 |
493 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
288 |
254 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
547 |
546 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
265 |
94 |
$624.79 |
| D0220 |
Intraoral - periapical first radiographic image |
193 |
193 |
$247.01 |
| D7140 |
Extraction, erupted tooth or exposed root |
142 |
83 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
258 |
115 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
130 |
129 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
207 |
207 |
$0.00 |
| D0240 |
|
250 |
127 |
$0.00 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
36 |
12 |
$0.00 |
| D9994 |
|
14 |
14 |
$0.00 |
| D1351 |
Sealant - per tooth |
42 |
13 |
$0.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
50 |
15 |
$0.00 |