| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
596 |
103 |
$68K |
| D9420 |
|
270 |
163 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
195 |
194 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
148 |
148 |
$6K |
| D9430 |
|
194 |
194 |
$6K |
| D1120 |
Prophylaxis - child |
167 |
167 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
82 |
25 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
161 |
161 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
111 |
111 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
162 |
131 |
$705.90 |
| D0120 |
Periodic oral evaluation - established patient |
45 |
45 |
$126.00 |