| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
65 |
15 |
$8K |
| D1120 |
Prophylaxis - child |
185 |
184 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
57 |
13 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
186 |
185 |
$3K |
| D0272 |
Bitewings - two radiographic images |
76 |
76 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
45 |
45 |
$2K |
| D9420 |
|
12 |
12 |
$903.42 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$392.73 |
| D0220 |
Intraoral - periapical first radiographic image |
24 |
24 |
$301.62 |
| D0120 |
Periodic oral evaluation - established patient |
12 |
12 |
$278.39 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$108.71 |