| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
453 |
453 |
$14K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
104 |
28 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
276 |
276 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
456 |
456 |
$8K |
| D0272 |
Bitewings - two radiographic images |
362 |
358 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
499 |
493 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
171 |
166 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
466 |
459 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
99 |
99 |
$2K |
| D9420 |
|
26 |
26 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
28 |
13 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$626.81 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$392.34 |