| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
303 |
118 |
$26K |
| D1120 |
Prophylaxis - child |
378 |
377 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
150 |
150 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
150 |
148 |
$5K |
| D1110 |
Prophylaxis - adult |
52 |
52 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
82 |
56 |
$3K |
| D9248 |
|
30 |
29 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
101 |
43 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$2K |
| D1351 |
Sealant - per tooth |
853 |
197 |
$1K |
| D0330 |
Panoramic radiographic image |
27 |
27 |
$745.51 |
| D1206 |
Topical application of fluoride varnish |
441 |
440 |
$553.81 |
| D1354 |
|
275 |
126 |
$340.00 |
| D0274 |
Bitewings - four radiographic images |
39 |
39 |
$157.30 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
234 |
227 |
$43.95 |
| D0220 |
Intraoral - periapical first radiographic image |
489 |
473 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
226 |
224 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
985 |
400 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
264 |
263 |
$-21.53 |