| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
762 |
761 |
$34K |
| D1206 |
Topical application of fluoride varnish |
916 |
916 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
771 |
771 |
$27K |
| D0274 |
Bitewings - four radiographic images |
70 |
70 |
$2K |
| D0602 |
|
118 |
118 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
64 |
64 |
$630.00 |
| D0272 |
Bitewings - two radiographic images |
29 |
29 |
$522.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
50 |
50 |
$416.00 |
| D0601 |
|
42 |
42 |
$390.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13 |
12 |
$325.00 |
| D1999 |
|
155 |
147 |
$0.00 |
| D1330 |
|
341 |
336 |
$0.00 |