| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
73 |
73 |
$3K |
| D1351 |
Sealant - per tooth |
89 |
12 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
81 |
81 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$2K |
| D1206 |
Topical application of fluoride varnish |
88 |
88 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
99 |
64 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
65 |
65 |
$791.28 |
| D0272 |
Bitewings - two radiographic images |
34 |
34 |
$771.54 |
| D0274 |
Bitewings - four radiographic images |
15 |
15 |
$484.54 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$423.84 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13 |
12 |
$298.21 |
| D0603 |
|
108 |
108 |
$0.00 |