| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
24 |
24 |
$3K |
| D1351 |
Sealant - per tooth |
62 |
16 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
53 |
53 |
$2K |
| D1120 |
Prophylaxis - child |
38 |
38 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
35 |
35 |
$1K |
| D1110 |
Prophylaxis - adult |
16 |
16 |
$878.08 |
| D0230 |
Intraoral - periapical each additional radiographic image |
266 |
55 |
$863.25 |
| D1208 |
Topical application of fluoride, excluding varnish |
54 |
54 |
$793.80 |
| D0220 |
Intraoral - periapical first radiographic image |
67 |
64 |
$389.36 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
15 |
12 |
$379.54 |
| D0603 |
|
78 |
78 |
$0.00 |