| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
16 |
15 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
51 |
36 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
12 |
12 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
68 |
68 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
13 |
$923.42 |
| D1206 |
Topical application of fluoride varnish |
27 |
27 |
$591.76 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$208.04 |
| D0240 |
|
16 |
15 |
$168.60 |
| D3120 |
|
12 |
12 |
$0.00 |