| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
148 |
49 |
$18K |
| D1120 |
Prophylaxis - child |
310 |
310 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
168 |
76 |
$12K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
114 |
47 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
256 |
256 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
314 |
314 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
78 |
51 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
84 |
78 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
206 |
93 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
157 |
149 |
$2K |
| D0272 |
Bitewings - two radiographic images |
114 |
113 |
$2K |
| D0330 |
Panoramic radiographic image |
36 |
36 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
48 |
48 |
$1K |
| D1351 |
Sealant - per tooth |
62 |
25 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
23 |
14 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
16 |
15 |
$552.75 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$359.97 |
| D9420 |
|
12 |
12 |
$0.00 |