| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
157 |
30 |
$19K |
| D1120 |
Prophylaxis - child |
364 |
316 |
$13K |
| D1206 |
Topical application of fluoride varnish |
441 |
380 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
246 |
238 |
$6K |
| D1110 |
Prophylaxis - adult |
129 |
115 |
$6K |
| D0274 |
Bitewings - four radiographic images |
116 |
98 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
38 |
12 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
49 |
49 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
120 |
119 |
$3K |
| D0330 |
Panoramic radiographic image |
51 |
36 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
41 |
40 |
$2K |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$300.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$120.00 |