| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
33 |
33 |
$5K |
| D1120 |
Prophylaxis - child |
106 |
106 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
126 |
126 |
$4K |
| D1206 |
Topical application of fluoride varnish |
176 |
176 |
$2K |
| D1110 |
Prophylaxis - adult |
37 |
37 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
132 |
62 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
83 |
82 |
$898.62 |
| D0274 |
Bitewings - four radiographic images |
22 |
22 |
$761.42 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
22 |
22 |
$590.22 |
| D0272 |
Bitewings - two radiographic images |
28 |
28 |
$584.50 |
| D0603 |
|
78 |
78 |
$0.00 |
| D0602 |
|
95 |
95 |
$0.00 |