| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
81 |
81 |
$2K |
| D0274 |
Bitewings - four radiographic images |
71 |
71 |
$2K |
| D1110 |
Prophylaxis - adult |
29 |
29 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
91 |
91 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
80 |
71 |
$886.27 |
| D1120 |
Prophylaxis - child |
25 |
25 |
$882.00 |
| D1206 |
Topical application of fluoride varnish |
39 |
39 |
$529.20 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
12 |
$379.54 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$353.20 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$176.40 |
| D0602 |
|
179 |
178 |
$0.00 |