| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
400 |
61 |
$44K |
| D1120 |
Prophylaxis - child |
918 |
918 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
1,268 |
1,268 |
$33K |
| D1110 |
Prophylaxis - adult |
506 |
506 |
$23K |
| D1206 |
Topical application of fluoride varnish |
561 |
561 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
563 |
563 |
$8K |
| D0272 |
Bitewings - two radiographic images |
291 |
291 |
$5K |
| D0330 |
Panoramic radiographic image |
95 |
95 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
46 |
15 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
13 |
$957.00 |
| D1999 |
|
46 |
46 |
$0.00 |