| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
99 |
20 |
$12K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
22 |
13 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
24 |
16 |
$2K |
| D1120 |
Prophylaxis - child |
51 |
51 |
$2K |
| D1206 |
Topical application of fluoride varnish |
63 |
63 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
44 |
44 |
$938.96 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
30 |
30 |
$823.20 |
| D0272 |
Bitewings - two radiographic images |
31 |
31 |
$566.99 |
| D0220 |
Intraoral - periapical first radiographic image |
26 |
25 |
$396.24 |
| D0230 |
Intraoral - periapical each additional radiographic image |
20 |
12 |
$152.40 |