| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
729 |
696 |
$250.52 |
| D0120 |
Periodic oral evaluation - established patient |
660 |
629 |
$182.00 |
| D1206 |
Topical application of fluoride varnish |
750 |
719 |
$141.15 |
| D0220 |
Intraoral - periapical first radiographic image |
622 |
595 |
$60.71 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
34 |
31 |
$58.29 |
| D0230 |
Intraoral - periapical each additional radiographic image |
549 |
522 |
$48.88 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
55 |
54 |
$29.72 |
| D0272 |
Bitewings - two radiographic images |
514 |
490 |
$23.90 |
| D0274 |
Bitewings - four radiographic images |
14 |
12 |
$0.00 |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$0.00 |