| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
131 |
24 |
$27K |
| D9630 |
|
121 |
118 |
$5K |
| D1120 |
Prophylaxis - child |
190 |
187 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
105 |
102 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
73 |
72 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
226 |
217 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
44 |
44 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
624 |
214 |
$1K |
| D1206 |
Topical application of fluoride varnish |
38 |
37 |
$1K |
| D9999 |
Unspecified adjunctive procedure, by report |
28 |
28 |
$1K |
| D0272 |
Bitewings - two radiographic images |
62 |
60 |
$627.69 |