| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
207 |
207 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
197 |
197 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
157 |
157 |
$5K |
| D1351 |
Sealant - per tooth |
71 |
15 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
184 |
182 |
$700.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
171 |
170 |
$630.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
27 |
24 |
$620.00 |
| D0272 |
Bitewings - two radiographic images |
58 |
58 |
$560.00 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$158.00 |
| D1330 |
|
208 |
208 |
$0.00 |