| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
334 |
333 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
268 |
268 |
$108.50 |
| D1206 |
Topical application of fluoride varnish |
230 |
229 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
40 |
12 |
$0.00 |
| D1330 |
|
377 |
376 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
145 |
145 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
104 |
104 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
70 |
70 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
55 |
55 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
14 |
$0.00 |