| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
821 |
619 |
$24K |
| D1206 |
Topical application of fluoride varnish |
1,111 |
817 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
986 |
736 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
182 |
132 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
255 |
67 |
$1K |
| D0274 |
Bitewings - four radiographic images |
45 |
27 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
16 |
13 |
$495.20 |
| D0272 |
Bitewings - two radiographic images |
16 |
12 |
$322.53 |