| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
611 |
609 |
$22K |
| D9420 |
|
316 |
316 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
704 |
702 |
$15K |
| D7140 |
Extraction, erupted tooth or exposed root |
185 |
93 |
$14K |
| D2335 |
|
52 |
24 |
$10K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
56 |
24 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
28 |
13 |
$6K |
| D1206 |
Topical application of fluoride varnish |
174 |
174 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
15 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
227 |
226 |
$3K |
| D0272 |
Bitewings - two radiographic images |
39 |
39 |
$546.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$330.00 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$167.30 |
| D1330 |
|
238 |
238 |
$0.00 |