| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
70 |
70 |
$2K |
| D1120 |
Prophylaxis - child |
39 |
39 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13 |
12 |
$598.00 |
| D0220 |
Intraoral - periapical first radiographic image |
31 |
31 |
$586.03 |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$575.49 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$566.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
18 |
18 |
$434.67 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
13 |
$192.76 |