| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
919 |
919 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
954 |
953 |
$29K |
| D1206 |
Topical application of fluoride varnish |
993 |
992 |
$26K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
83 |
40 |
$13K |
| D0272 |
Bitewings - two radiographic images |
511 |
509 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
98 |
43 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
72 |
39 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
88 |
88 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
42 |
24 |
$3K |
| D0240 |
|
66 |
60 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
16 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
25 |
25 |
$500.00 |