| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,294 |
491 |
$2K |
| D1120 |
Prophylaxis - child |
3,026 |
2,974 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
2,422 |
2,371 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,653 |
2,628 |
$414.96 |
| D7140 |
Extraction, erupted tooth or exposed root |
744 |
423 |
$398.64 |
| D0272 |
Bitewings - two radiographic images |
1,106 |
1,087 |
$309.60 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
596 |
592 |
$186.60 |
| D1351 |
Sealant - per tooth |
757 |
285 |
$179.34 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
375 |
209 |
$167.20 |
| D0240 |
|
766 |
574 |
$116.97 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
155 |
89 |
$84.80 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
223 |
220 |
$44.94 |
| D0140 |
Limited oral evaluation - problem focused |
368 |
362 |
$38.43 |
| D0220 |
Intraoral - periapical first radiographic image |
184 |
177 |
$31.20 |
| D0145 |
Oral evaluation for a patient under three years of age |
274 |
274 |
$0.00 |
| D0330 |
Panoramic radiographic image |
107 |
107 |
$0.00 |
| D2929 |
|
74 |
32 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
210 |
210 |
$0.00 |
| D9920 |
|
781 |
776 |
$0.00 |
| D9310 |
|
361 |
361 |
$0.00 |
| D2331 |
|
129 |
66 |
$0.00 |
| D7111 |
|
82 |
58 |
$0.00 |
| D2330 |
|
204 |
113 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
109 |
66 |
$0.00 |