| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1354 |
|
288 |
71 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
38 |
19 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
24 |
14 |
$4K |
| D1110 |
Prophylaxis - adult |
74 |
69 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
118 |
116 |
$3K |
| D1120 |
Prophylaxis - child |
70 |
68 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
40 |
31 |
$3K |
| D1206 |
Topical application of fluoride varnish |
121 |
114 |
$2K |
| D0274 |
Bitewings - four radiographic images |
76 |
73 |
$2K |
| D0272 |
Bitewings - two radiographic images |
64 |
63 |
$1K |
| D2160 |
|
13 |
12 |
$883.26 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
18 |
18 |
$874.48 |
| D0330 |
Panoramic radiographic image |
20 |
20 |
$835.64 |
| D2140 |
|
14 |
13 |
$761.64 |
| D9920 |
|
13 |
13 |
$744.52 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$509.25 |