| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
34 |
33 |
$1K |
| D0274 |
Bitewings - four radiographic images |
27 |
27 |
$815.76 |
| D1206 |
Topical application of fluoride varnish |
36 |
35 |
$677.08 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
18 |
17 |
$621.19 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
16 |
16 |
$460.44 |
| D0220 |
Intraoral - periapical first radiographic image |
33 |
33 |
$367.61 |
| D0230 |
Intraoral - periapical each additional radiographic image |
31 |
31 |
$298.66 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$257.62 |