| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
37 |
27 |
$698.99 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
19 |
14 |
$621.88 |
| D0140 |
Limited oral evaluation - problem focused |
18 |
17 |
$437.92 |
| D1120 |
Prophylaxis - child |
18 |
13 |
$418.21 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
13 |
$392.00 |
| D0220 |
Intraoral - periapical first radiographic image |
40 |
36 |
$315.70 |
| D0272 |
Bitewings - two radiographic images |
19 |
18 |
$185.22 |
| D0230 |
Intraoral - periapical each additional radiographic image |
79 |
35 |
$180.12 |