| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
101 |
101 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
313 |
154 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
185 |
183 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
83 |
83 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
158 |
155 |
$2K |
| D0274 |
Bitewings - four radiographic images |
50 |
49 |
$2K |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$713.44 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
15 |
$529.80 |
| D0272 |
Bitewings - two radiographic images |
17 |
17 |
$396.99 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13 |
13 |
$325.32 |
| D0603 |
|
199 |
197 |
$0.00 |