| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
548 |
83 |
$73K |
| D0145 |
Oral evaluation for a patient under three years of age |
25 |
25 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
337 |
199 |
$3K |
| D9420 |
|
92 |
88 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
243 |
228 |
$3K |
| D0170 |
|
162 |
160 |
$3K |
| D1351 |
Sealant - per tooth |
95 |
35 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
42 |
16 |
$2K |
| D0272 |
Bitewings - two radiographic images |
104 |
95 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
54 |
53 |
$2K |
| D1120 |
Prophylaxis - child |
28 |
28 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
60 |
60 |
$867.30 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$382.10 |
| D0603 |
|
270 |
267 |
$0.00 |