| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
116 |
116 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
12 |
12 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
31 |
31 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
239 |
237 |
$973.82 |
| D0272 |
Bitewings - two radiographic images |
47 |
47 |
$349.00 |
| D1120 |
Prophylaxis - child |
201 |
201 |
$193.94 |
| D0230 |
Intraoral - periapical each additional radiographic image |
447 |
221 |
$87.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
224 |
224 |
$62.00 |
| D1330 |
|
227 |
227 |
$30.00 |
| D0601 |
|
14 |
13 |
$0.00 |
| D0603 |
|
13 |
13 |
$0.00 |