| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
84 |
84 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
24 |
24 |
$2K |
| D1110 |
Prophylaxis - adult |
16 |
16 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
17 |
17 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
28 |
28 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
63 |
25 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
45 |
45 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
61 |
61 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
75 |
75 |
$0.00 |