| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
23 |
23 |
$3K |
| D1120 |
Prophylaxis - child |
76 |
76 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
249 |
96 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
85 |
85 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
99 |
99 |
$1K |
| D1351 |
Sealant - per tooth |
42 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
100 |
100 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
27 |
27 |
$731.97 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$658.56 |
| D0274 |
Bitewings - four radiographic images |
15 |
15 |
$519.15 |
| D0272 |
Bitewings - two radiographic images |
20 |
20 |
$420.84 |
| D0603 |
|
135 |
135 |
$0.00 |