| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
174 |
172 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
114 |
113 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
33 |
12 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
33 |
12 |
$3K |
| D1310 |
|
68 |
67 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
704 |
135 |
$3K |
| D1206 |
Topical application of fluoride varnish |
102 |
101 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
36 |
16 |
$2K |
| D1351 |
Sealant - per tooth |
50 |
12 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
26 |
24 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$767.00 |
| D0272 |
Bitewings - two radiographic images |
67 |
66 |
$744.00 |
| D0274 |
Bitewings - four radiographic images |
13 |
12 |
$259.20 |
| D0603 |
|
14 |
14 |
$195.00 |
| D1330 |
|
15 |
15 |
$0.00 |