| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
240 |
238 |
$7K |
| D1120 |
Prophylaxis - child |
162 |
161 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
261 |
259 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
99 |
96 |
$3K |
| D0272 |
Bitewings - two radiographic images |
95 |
95 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$2K |
| D1351 |
Sealant - per tooth |
51 |
14 |
$1K |
| D0274 |
Bitewings - four radiographic images |
26 |
26 |
$868.65 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$653.07 |
| D0220 |
Intraoral - periapical first radiographic image |
31 |
31 |
$346.64 |
| D0230 |
Intraoral - periapical each additional radiographic image |
24 |
14 |
$199.29 |
| D0603 |
|
367 |
363 |
$0.00 |