| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
319 |
310 |
$17K |
| D1110 |
Prophylaxis - adult |
65 |
65 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
90 |
89 |
$4K |
| D0330 |
Panoramic radiographic image |
20 |
18 |
$2K |
| D0274 |
Bitewings - four radiographic images |
176 |
173 |
$443.46 |
| D0120 |
Periodic oral evaluation - established patient |
272 |
264 |
$273.61 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
27 |
27 |
$47.38 |
| D1208 |
Topical application of fluoride, excluding varnish |
376 |
367 |
$15.00 |
| D0272 |
Bitewings - two radiographic images |
111 |
107 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
90 |
88 |
$0.00 |
| D1330 |
|
340 |
332 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
113 |
109 |
$0.00 |