| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
396 |
121 |
$41K |
| D7140 |
Extraction, erupted tooth or exposed root |
413 |
164 |
$25K |
| D1120 |
Prophylaxis - child |
833 |
828 |
$20K |
| D1206 |
Topical application of fluoride varnish |
1,038 |
1,032 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
694 |
692 |
$13K |
| D0272 |
Bitewings - two radiographic images |
488 |
485 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
198 |
197 |
$5K |
| D1351 |
Sealant - per tooth |
196 |
57 |
$4K |
| D1110 |
Prophylaxis - adult |
93 |
93 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
94 |
93 |
$2K |
| D0240 |
|
64 |
55 |
$749.74 |
| D0220 |
Intraoral - periapical first radiographic image |
68 |
67 |
$365.96 |