| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
125 |
125 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
108 |
108 |
$2K |
| D1120 |
Prophylaxis - child |
46 |
46 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
12 |
12 |
$486.50 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$290.73 |
| D0220 |
Intraoral - periapical first radiographic image |
36 |
36 |
$252.85 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$224.08 |
| D0272 |
Bitewings - two radiographic images |
18 |
18 |
$207.66 |
| D0230 |
Intraoral - periapical each additional radiographic image |
31 |
31 |
$181.15 |