| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
207 |
207 |
$10K |
| D0274 |
Bitewings - four radiographic images |
230 |
230 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
260 |
260 |
$6K |
| D1120 |
Prophylaxis - child |
56 |
56 |
$2K |
| D1206 |
Topical application of fluoride varnish |
73 |
73 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
46 |
46 |
$745.20 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$701.26 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
15 |
$582.11 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
13 |
$455.00 |