| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
466 |
462 |
$14K |
| D9920 |
|
98 |
93 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
584 |
580 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
458 |
452 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
81 |
30 |
$5K |
| D1110 |
Prophylaxis - adult |
120 |
120 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
176 |
175 |
$4K |
| D0272 |
Bitewings - two radiographic images |
165 |
165 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
23 |
13 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
23 |
13 |
$2K |
| D1310 |
|
59 |
59 |
$681.10 |
| D1330 |
|
55 |
55 |
$637.15 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$336.00 |
| D0220 |
Intraoral - periapical first radiographic image |
28 |
25 |
$218.00 |
| D1999 |
|
84 |
72 |
$0.00 |