| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
316 |
309 |
$41K |
| D1120 |
Prophylaxis - child |
740 |
738 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
622 |
620 |
$18K |
| D1206 |
Topical application of fluoride varnish |
776 |
774 |
$10K |
| D0272 |
Bitewings - two radiographic images |
260 |
259 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
439 |
417 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
366 |
356 |
$4K |
| D1351 |
Sealant - per tooth |
85 |
13 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
15 |
15 |
$379.54 |
| D0602 |
|
716 |
710 |
$0.00 |
| D1330 |
|
49 |
49 |
$0.00 |
| D0603 |
|
807 |
727 |
$0.00 |