| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
61 |
38 |
$0.00 |
| D1120 |
Prophylaxis - child |
68 |
68 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$0.00 |
| D1351 |
Sealant - per tooth |
41 |
13 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
30 |
30 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
12 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
37 |
37 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
72 |
72 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
48 |
48 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$0.00 |