| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
426 |
425 |
$16K |
| D1206 |
Topical application of fluoride varnish |
502 |
501 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
412 |
411 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
61 |
61 |
$3K |
| D0274 |
Bitewings - four radiographic images |
119 |
119 |
$3K |
| D1110 |
Prophylaxis - adult |
28 |
28 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
49 |
49 |
$1K |
| D9920 |
|
48 |
48 |
$1K |
| D0272 |
Bitewings - two radiographic images |
41 |
41 |
$670.00 |
| D0240 |
|
42 |
18 |
$375.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$350.00 |
| D0220 |
Intraoral - periapical first radiographic image |
33 |
33 |
$165.00 |
| D0601 |
|
12 |
12 |
$120.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
30 |
30 |
$105.00 |