| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
346 |
66 |
$50K |
| D1120 |
Prophylaxis - child |
391 |
366 |
$10K |
| D1206 |
Topical application of fluoride varnish |
217 |
208 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
102 |
102 |
$3K |
| D0272 |
Bitewings - two radiographic images |
135 |
133 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
24 |
13 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
52 |
42 |
$1K |
| D0240 |
|
31 |
15 |
$391.20 |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
15 |
$270.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$55.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$55.00 |