| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
126 |
124 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
62 |
62 |
$2K |
| D1206 |
Topical application of fluoride varnish |
82 |
80 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
104 |
104 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
16 |
12 |
$923.04 |
| D1208 |
Topical application of fluoride, excluding varnish |
58 |
58 |
$795.00 |
| D0272 |
Bitewings - two radiographic images |
38 |
38 |
$727.05 |
| D0220 |
Intraoral - periapical first radiographic image |
26 |
26 |
$187.96 |
| D1330 |
|
38 |
37 |
$0.00 |
| D1999 |
|
120 |
104 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
24 |
24 |
$0.00 |