| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
133 |
27 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
173 |
82 |
$12K |
| D1120 |
Prophylaxis - child |
136 |
136 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
225 |
225 |
$4K |
| D1206 |
Topical application of fluoride varnish |
200 |
200 |
$4K |
| D1110 |
Prophylaxis - adult |
77 |
77 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
12 |
$2K |
| D0330 |
Panoramic radiographic image |
33 |
33 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
53 |
53 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
75 |
74 |
$838.50 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$282.10 |