| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
120 |
17 |
$3K |
| D1120 |
Prophylaxis - child |
72 |
72 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
87 |
86 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
17 |
17 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
180 |
94 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
95 |
94 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
101 |
100 |
$1K |
| D0272 |
Bitewings - two radiographic images |
40 |
40 |
$935.20 |
| D1110 |
Prophylaxis - adult |
18 |
17 |
$932.96 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
22 |
19 |
$596.42 |
| D0274 |
Bitewings - four radiographic images |
18 |
17 |
$588.37 |
| D0603 |
|
80 |
79 |
$0.00 |
| D0601 |
|
36 |
35 |
$0.00 |