| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
27 |
19 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
42 |
27 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
47 |
44 |
$2K |
| D8670 |
Periodic orthodontic treatment visit |
17 |
17 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
29 |
21 |
$1K |
| D1351 |
Sealant - per tooth |
43 |
16 |
$925.00 |
| D1120 |
Prophylaxis - child |
28 |
28 |
$840.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
32 |
32 |
$647.20 |
| D1206 |
Topical application of fluoride varnish |
33 |
33 |
$594.00 |
| D0120 |
Periodic oral evaluation - established patient |
22 |
22 |
$440.00 |
| D0272 |
Bitewings - two radiographic images |
24 |
24 |
$384.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$96.00 |
| D1999 |
|
128 |
120 |
$0.00 |