| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
100 |
100 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
63 |
62 |
$1K |
| D1206 |
Topical application of fluoride varnish |
97 |
97 |
$1K |
| D0272 |
Bitewings - two radiographic images |
61 |
61 |
$816.79 |
| D0120 |
Periodic oral evaluation - established patient |
36 |
36 |
$573.12 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13 |
13 |
$525.20 |
| D0220 |
Intraoral - periapical first radiographic image |
30 |
30 |
$241.20 |
| D0230 |
Intraoral - periapical each additional radiographic image |
18 |
13 |
$105.66 |