| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
264 |
53 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
171 |
171 |
$3K |
| D1120 |
Prophylaxis - child |
117 |
117 |
$2K |
| D1110 |
Prophylaxis - adult |
56 |
56 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
218 |
217 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
179 |
179 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
195 |
195 |
$1K |
| D0274 |
Bitewings - four radiographic images |
59 |
59 |
$1K |
| D0272 |
Bitewings - two radiographic images |
86 |
86 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
30 |
30 |
$529.80 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13 |
13 |
$176.28 |
| D0603 |
|
92 |
92 |
$0.00 |
| D0602 |
|
132 |
131 |
$0.00 |