| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
230 |
230 |
$6K |
| D1120 |
Prophylaxis - child |
175 |
175 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
406 |
405 |
$5K |
| D0272 |
Bitewings - two radiographic images |
59 |
59 |
$1K |
| D1351 |
Sealant - per tooth |
47 |
13 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
42 |
40 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
45 |
25 |
$516.80 |
| D0220 |
Intraoral - periapical first radiographic image |
45 |
44 |
$500.26 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$493.92 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$349.71 |
| D0603 |
|
553 |
549 |
$0.00 |