| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
637 |
637 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
540 |
540 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
650 |
650 |
$4K |
| D0272 |
Bitewings - two radiographic images |
396 |
396 |
$2K |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$169.02 |
| D0220 |
Intraoral - periapical first radiographic image |
40 |
40 |
$154.92 |
| D0274 |
Bitewings - four radiographic images |
22 |
22 |
$144.69 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$46.62 |
| D1330 |
|
581 |
581 |
$0.00 |
| D9215 |
|
14 |
14 |
$0.00 |
| D9630 |
|
13 |
13 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
204 |
201 |
$0.00 |