| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
126 |
33 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
329 |
321 |
$19K |
| D1120 |
Prophylaxis - child |
304 |
297 |
$14K |
| D1330 |
|
359 |
350 |
$12K |
| D1206 |
Topical application of fluoride varnish |
289 |
289 |
$9K |
| D0240 |
|
207 |
120 |
$9K |
| D0272 |
Bitewings - two radiographic images |
161 |
161 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
21 |
13 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
37 |
35 |
$866.83 |
| D0220 |
Intraoral - periapical first radiographic image |
33 |
32 |
$846.28 |
| D0230 |
Intraoral - periapical each additional radiographic image |
31 |
16 |
$520.26 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$497.88 |