| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
77 |
73 |
$10K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
65 |
14 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
464 |
155 |
$5K |
| D1120 |
Prophylaxis - child |
135 |
132 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
144 |
138 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
39 |
12 |
$3K |
| D1206 |
Topical application of fluoride varnish |
145 |
141 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
172 |
167 |
$2K |
| D0274 |
Bitewings - four radiographic images |
73 |
63 |
$2K |
| D9248 |
|
14 |
13 |
$2K |
| D1110 |
Prophylaxis - adult |
31 |
28 |
$1K |
| D1351 |
Sealant - per tooth |
46 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$584.50 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
17 |
16 |
$352.43 |
| D0350 |
|
17 |
17 |
$238.94 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$118.20 |
| D0603 |
|
236 |
226 |
$0.00 |