| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0274 |
Bitewings - four radiographic images |
41 |
41 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
46 |
46 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
20 |
20 |
$844.00 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$790.81 |
| D0220 |
Intraoral - periapical first radiographic image |
39 |
39 |
$507.77 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
13 |
$480.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$462.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
16 |
$304.00 |