| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
72 |
72 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
88 |
88 |
$1K |
| D0272 |
Bitewings - two radiographic images |
62 |
62 |
$724.78 |
| D0220 |
Intraoral - periapical first radiographic image |
99 |
99 |
$634.28 |
| D0230 |
Intraoral - periapical each additional radiographic image |
79 |
79 |
$460.78 |
| D1208 |
Topical application of fluoride, excluding varnish |
47 |
47 |
$360.15 |
| D1206 |
Topical application of fluoride varnish |
41 |
41 |
$301.35 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
18 |
17 |
$244.08 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$242.21 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$145.70 |
| D0603 |
|
85 |
85 |
$0.00 |
| D0602 |
|
24 |
24 |
$0.00 |