| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
209 |
47 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
296 |
91 |
$17K |
| D1120 |
Prophylaxis - child |
385 |
379 |
$8K |
| D2933 |
|
53 |
14 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
367 |
363 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
251 |
249 |
$4K |
| D0272 |
Bitewings - two radiographic images |
396 |
387 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
141 |
138 |
$3K |
| D0240 |
|
150 |
107 |
$2K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$555.84 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
21 |
21 |
$553.35 |
| D0220 |
Intraoral - periapical first radiographic image |
89 |
89 |
$445.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
47 |
44 |
$250.00 |
| D1999 |
|
52 |
49 |
$0.00 |