| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
566 |
566 |
$26K |
| D1206 |
Topical application of fluoride varnish |
580 |
580 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
459 |
459 |
$12K |
| D0272 |
Bitewings - two radiographic images |
195 |
195 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
56 |
56 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
32 |
32 |
$890.00 |
| D0220 |
Intraoral - periapical first radiographic image |
77 |
76 |
$684.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
26 |
26 |
$105.00 |