| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
184 |
70 |
$20K |
| D1120 |
Prophylaxis - child |
676 |
676 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
683 |
683 |
$12K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
178 |
67 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
747 |
747 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
84 |
44 |
$5K |
| D0272 |
Bitewings - two radiographic images |
360 |
360 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
71 |
71 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
65 |
65 |
$971.25 |
| D0220 |
Intraoral - periapical first radiographic image |
167 |
167 |
$876.75 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$632.32 |
| D1110 |
Prophylaxis - adult |
15 |
15 |
$537.60 |