| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
204 |
32 |
$21K |
| D1120 |
Prophylaxis - child |
449 |
360 |
$13K |
| D1206 |
Topical application of fluoride varnish |
441 |
355 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
273 |
214 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
76 |
13 |
$4K |
| D0272 |
Bitewings - two radiographic images |
198 |
156 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
38 |
14 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
52 |
39 |
$2K |
| D0240 |
|
35 |
13 |
$550.32 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
15 |
13 |
$450.00 |
| D0220 |
Intraoral - periapical first radiographic image |
22 |
16 |
$167.11 |
| D0230 |
Intraoral - periapical each additional radiographic image |
19 |
13 |
$137.62 |