| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
102 |
99 |
$4K |
| D1120 |
Prophylaxis - child |
102 |
99 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
47 |
45 |
$768.10 |
| D0272 |
Bitewings - two radiographic images |
35 |
35 |
$630.25 |
| D1206 |
Topical application of fluoride varnish |
24 |
24 |
$576.15 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
17 |
14 |
$548.24 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$545.20 |
| D0220 |
Intraoral - periapical first radiographic image |
37 |
37 |
$470.84 |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
12 |
$131.34 |