| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,066 |
2,065 |
$75K |
| D0120 |
Periodic oral evaluation - established patient |
1,866 |
1,866 |
$55K |
| D1206 |
Topical application of fluoride varnish |
1,287 |
1,287 |
$30K |
| D0272 |
Bitewings - two radiographic images |
910 |
910 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
679 |
678 |
$17K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
71 |
27 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
243 |
241 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
28 |
12 |
$4K |
| D0240 |
|
174 |
91 |
$4K |
| D9248 |
|
13 |
13 |
$730.57 |
| D0230 |
Intraoral - periapical each additional radiographic image |
27 |
12 |
$350.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
511 |
472 |
$0.00 |