| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
62 |
62 |
$3K |
| D1206 |
Topical application of fluoride varnish |
45 |
45 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
32 |
32 |
$864.24 |
| D0330 |
Panoramic radiographic image |
28 |
28 |
$577.36 |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$542.11 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
17 |
17 |
$465.36 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$432.12 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
20 |
19 |
$368.80 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$296.94 |
| D1208 |
Topical application of fluoride, excluding varnish |
20 |
20 |
$194.56 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$188.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$64.79 |
| D1330 |
|
16 |
16 |
$0.00 |