| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
45 |
45 |
$828.04 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
18 |
18 |
$585.00 |
| D1206 |
Topical application of fluoride varnish |
21 |
21 |
$425.00 |
| D0220 |
Intraoral - periapical first radiographic image |
16 |
15 |
$173.01 |
| D1208 |
Topical application of fluoride, excluding varnish |
26 |
26 |
$130.06 |
| D0120 |
Periodic oral evaluation - established patient |
28 |
28 |
$95.71 |
| D0230 |
Intraoral - periapical each additional radiographic image |
17 |
14 |
$82.59 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
17 |
15 |
$0.00 |