| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
201 |
200 |
$6K |
| D1120 |
Prophylaxis - child |
164 |
164 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
168 |
168 |
$4K |
| D0272 |
Bitewings - two radiographic images |
128 |
128 |
$2K |
| D1351 |
Sealant - per tooth |
53 |
15 |
$1K |
| D1110 |
Prophylaxis - adult |
35 |
35 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
24 |
24 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
26 |
26 |
$740.52 |
| D0274 |
Bitewings - four radiographic images |
35 |
35 |
$662.94 |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
14 |
$622.86 |
| D1354 |
|
41 |
15 |
$492.82 |
| D0220 |
Intraoral - periapical first radiographic image |
70 |
69 |
$490.28 |
| D0230 |
Intraoral - periapical each additional radiographic image |
72 |
61 |
$426.00 |
| D0330 |
Panoramic radiographic image |
27 |
27 |
$0.00 |