| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
320 |
73 |
$33K |
| D1120 |
Prophylaxis - child |
420 |
417 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
135 |
57 |
$8K |
| D1206 |
Topical application of fluoride varnish |
507 |
502 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
374 |
372 |
$6K |
| D0272 |
Bitewings - two radiographic images |
295 |
293 |
$3K |
| D1351 |
Sealant - per tooth |
142 |
45 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
93 |
93 |
$2K |
| D1110 |
Prophylaxis - adult |
29 |
29 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
29 |
29 |
$665.24 |
| D0240 |
|
32 |
20 |
$401.22 |
| D0220 |
Intraoral - periapical first radiographic image |
29 |
26 |
$135.40 |