| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
85 |
15 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
49 |
49 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
31 |
12 |
$1K |
| D1120 |
Prophylaxis - child |
27 |
27 |
$881.46 |
| D0220 |
Intraoral - periapical first radiographic image |
64 |
63 |
$664.50 |
| D1208 |
Topical application of fluoride, excluding varnish |
31 |
31 |
$578.02 |
| D0230 |
Intraoral - periapical each additional radiographic image |
55 |
54 |
$549.59 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$438.22 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$424.55 |
| D0272 |
Bitewings - two radiographic images |
16 |
16 |
$151.97 |
| D0350 |
|
16 |
16 |
$147.04 |