| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9420 |
|
79 |
79 |
$37K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
124 |
37 |
$10K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
47 |
16 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
56 |
55 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
128 |
56 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
58 |
29 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
119 |
115 |
$2K |
| 41115 |
|
14 |
14 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
138 |
131 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
93 |
88 |
$2K |
| D1351 |
Sealant - per tooth |
123 |
31 |
$2K |
| D0272 |
Bitewings - two radiographic images |
67 |
66 |
$1K |
| D1330 |
|
110 |
105 |
$1K |
| D1120 |
Prophylaxis - child |
83 |
82 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
12 |
$921.54 |
| D0330 |
Panoramic radiographic image |
35 |
34 |
$642.13 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
14 |
$318.08 |
| D0220 |
Intraoral - periapical first radiographic image |
47 |
47 |
$285.43 |
| D0350 |
|
18 |
14 |
$282.77 |
| D1110 |
Prophylaxis - adult |
15 |
12 |
$26.75 |