| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
122 |
122 |
$5K |
| D0330 |
Panoramic radiographic image |
70 |
70 |
$3K |
| D1120 |
Prophylaxis - child |
109 |
108 |
$2K |
| D1206 |
Topical application of fluoride varnish |
151 |
150 |
$2K |
| D1110 |
Prophylaxis - adult |
30 |
30 |
$894.00 |
| D0272 |
Bitewings - two radiographic images |
59 |
59 |
$868.00 |
| D0274 |
Bitewings - four radiographic images |
17 |
17 |
$365.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$352.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$308.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
12 |
12 |
$286.00 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
12 |
$128.00 |