| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
462 |
462 |
$20K |
| D1206 |
Topical application of fluoride varnish |
475 |
475 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
226 |
226 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
227 |
227 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
211 |
211 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$1K |
| D0272 |
Bitewings - two radiographic images |
27 |
27 |
$629.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
18 |
14 |
$564.66 |