| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
577 |
163 |
$66K |
| D1120 |
Prophylaxis - child |
1,161 |
1,161 |
$33K |
| D1206 |
Topical application of fluoride varnish |
1,185 |
1,185 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
814 |
814 |
$16K |
| D9310 |
|
263 |
263 |
$12K |
| D0272 |
Bitewings - two radiographic images |
574 |
574 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
307 |
307 |
$9K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
66 |
36 |
$6K |
| D0240 |
|
122 |
122 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
117 |
117 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
64 |
58 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
173 |
103 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
44 |
44 |
$655.32 |