| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
25 |
25 |
$3K |
| D1351 |
Sealant - per tooth |
70 |
19 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
14 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
64 |
64 |
$2K |
| D1120 |
Prophylaxis - child |
37 |
37 |
$1K |
| D0272 |
Bitewings - two radiographic images |
51 |
51 |
$1K |
| D1206 |
Topical application of fluoride varnish |
63 |
63 |
$911.40 |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$713.44 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
18 |
18 |
$487.98 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$380.71 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$163.28 |
| D0603 |
|
108 |
108 |
$0.00 |