| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1999 |
|
813 |
557 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
992 |
805 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
615 |
535 |
$10K |
| D1120 |
Prophylaxis - child |
203 |
133 |
$3K |
| D1110 |
Prophylaxis - adult |
81 |
66 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
30 |
24 |
$620.80 |
| D0272 |
Bitewings - two radiographic images |
26 |
24 |
$387.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
60 |
15 |
$343.20 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$334.95 |
| D0274 |
Bitewings - four radiographic images |
13 |
12 |
$240.00 |
| D0220 |
Intraoral - periapical first radiographic image |
16 |
15 |
$138.60 |