| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
51 |
12 |
$10K |
| D1120 |
Prophylaxis - child |
196 |
195 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
73 |
25 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
139 |
139 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
593 |
233 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
117 |
117 |
$6K |
| D1206 |
Topical application of fluoride varnish |
180 |
180 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
258 |
250 |
$5K |
| D0272 |
Bitewings - two radiographic images |
107 |
106 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
68 |
67 |
$2K |
| D1110 |
Prophylaxis - adult |
29 |
29 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
15 |
$336.00 |