| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,178 |
166 |
$164K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
608 |
555 |
$17K |
| D9420 |
|
214 |
207 |
$7K |
| D0272 |
Bitewings - two radiographic images |
237 |
228 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
34 |
34 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
317 |
233 |
$3K |
| D0350 |
|
226 |
198 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
246 |
237 |
$3K |
| D1351 |
Sealant - per tooth |
93 |
26 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
88 |
84 |
$2K |
| D0170 |
|
80 |
79 |
$1K |
| D1120 |
Prophylaxis - child |
30 |
29 |
$955.50 |
| D1208 |
Topical application of fluoride, excluding varnish |
33 |
32 |
$426.30 |
| D0603 |
|
919 |
821 |
$0.00 |