| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
85 |
84 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
77 |
64 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
85 |
84 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
51 |
51 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
56 |
54 |
$637.00 |
| D0120 |
Periodic oral evaluation - established patient |
31 |
30 |
$630.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
48 |
45 |
$480.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$348.00 |