| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
109 |
33 |
$12K |
| D1120 |
Prophylaxis - child |
173 |
173 |
$6K |
| D1206 |
Topical application of fluoride varnish |
191 |
190 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
57 |
23 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
47 |
27 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
117 |
116 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
40 |
19 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
40 |
19 |
$2K |
| D1351 |
Sealant - per tooth |
78 |
21 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
80 |
80 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
49 |
49 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
105 |
105 |
$1K |
| D0272 |
Bitewings - two radiographic images |
90 |
90 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
115 |
100 |
$1K |
| D0330 |
Panoramic radiographic image |
23 |
23 |
$944.87 |
| D1110 |
Prophylaxis - adult |
19 |
19 |
$833.72 |
| D0140 |
Limited oral evaluation - problem focused |
18 |
18 |
$439.20 |
| D9420 |
|
16 |
16 |
$0.00 |