| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
86 |
84 |
$12K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
49 |
16 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
34 |
20 |
$3K |
| D9248 |
|
22 |
22 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
18 |
$3K |
| D1120 |
Prophylaxis - child |
66 |
64 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
70 |
69 |
$2K |
| D1110 |
Prophylaxis - adult |
27 |
27 |
$1K |
| D1206 |
Topical application of fluoride varnish |
97 |
95 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
119 |
94 |
$1K |
| D0272 |
Bitewings - two radiographic images |
59 |
57 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
104 |
102 |
$1K |
| D0274 |
Bitewings - four radiographic images |
28 |
28 |
$969.08 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
23 |
23 |
$596.42 |
| D0603 |
|
311 |
302 |
$0.00 |