| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
105 |
105 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
105 |
105 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
16 |
16 |
$2K |
| D1206 |
Topical application of fluoride varnish |
120 |
120 |
$2K |
| D0272 |
Bitewings - two radiographic images |
83 |
83 |
$2K |
| D1351 |
Sealant - per tooth |
54 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
126 |
126 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
125 |
121 |
$955.33 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$847.68 |
| D0330 |
Panoramic radiographic image |
19 |
19 |
$811.05 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$415.32 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
14 |
$379.54 |
| D0603 |
|
157 |
157 |
$0.00 |