| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
507 |
161 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
289 |
135 |
$5K |
| D1120 |
Prophylaxis - child |
428 |
428 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
377 |
377 |
$3K |
| D1206 |
Topical application of fluoride varnish |
444 |
444 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
93 |
93 |
$2K |
| D0272 |
Bitewings - two radiographic images |
119 |
119 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
252 |
247 |
$1K |
| D1351 |
Sealant - per tooth |
327 |
92 |
$689.40 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
96 |
96 |
$371.19 |
| D0274 |
Bitewings - four radiographic images |
56 |
56 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
57 |
57 |
$0.00 |
| D1110 |
Prophylaxis - adult |
16 |
16 |
$0.00 |
| D1330 |
|
42 |
42 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
98 |
53 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
29 |
29 |
$0.00 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
83 |
44 |
$0.00 |