| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
527 |
97 |
$63K |
| D2934 |
|
358 |
74 |
$49K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
492 |
99 |
$40K |
| D9420 |
|
119 |
118 |
$9K |
| D0272 |
Bitewings - two radiographic images |
115 |
113 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
74 |
74 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
119 |
117 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
115 |
113 |
$1K |
| D1120 |
Prophylaxis - child |
121 |
119 |
$842.93 |
| D1208 |
Topical application of fluoride, excluding varnish |
121 |
119 |
$501.50 |