| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
400 |
101 |
$24K |
| D1120 |
Prophylaxis - child |
778 |
773 |
$16K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
120 |
47 |
$13K |
| D1206 |
Topical application of fluoride varnish |
754 |
749 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
515 |
511 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
241 |
240 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
148 |
140 |
$3K |
| D0272 |
Bitewings - two radiographic images |
321 |
318 |
$3K |
| D0330 |
Panoramic radiographic image |
73 |
70 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
93 |
91 |
$476.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
36 |
15 |
$382.50 |