| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
46 |
12 |
$5K |
| D1120 |
Prophylaxis - child |
100 |
97 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
130 |
127 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
148 |
144 |
$2K |
| D9420 |
|
12 |
12 |
$780.67 |
| D0272 |
Bitewings - two radiographic images |
42 |
40 |
$609.15 |
| D0220 |
Intraoral - periapical first radiographic image |
67 |
63 |
$556.92 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
14 |
$436.54 |
| D0230 |
Intraoral - periapical each additional radiographic image |
21 |
17 |
$383.68 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$312.07 |
| D0240 |
|
29 |
29 |
$283.92 |