| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
91 |
91 |
$3K |
| D1206 |
Topical application of fluoride varnish |
90 |
90 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
77 |
77 |
$2K |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$1K |
| D0274 |
Bitewings - four radiographic images |
31 |
31 |
$978.36 |
| D0272 |
Bitewings - two radiographic images |
49 |
49 |
$962.78 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
16 |
16 |
$469.92 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$167.04 |
| D0603 |
|
16 |
16 |
$0.00 |