| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
247 |
247 |
$10K |
| D1120 |
Prophylaxis - child |
413 |
413 |
$9K |
| D1206 |
Topical application of fluoride varnish |
463 |
462 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
98 |
98 |
$2K |
| D0272 |
Bitewings - two radiographic images |
141 |
141 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
42 |
42 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
74 |
74 |
$740.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
32 |
24 |
$583.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$360.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
13 |
$113.00 |