| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
30 |
17 |
$6K |
| D1120 |
Prophylaxis - child |
100 |
100 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
64 |
64 |
$4K |
| D1206 |
Topical application of fluoride varnish |
103 |
103 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
13 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
45 |
45 |
$1K |
| D0272 |
Bitewings - two radiographic images |
42 |
42 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
50 |
50 |
$940.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
44 |
44 |
$574.00 |
| D0240 |
|
31 |
16 |
$550.00 |