| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
223 |
223 |
$4K |
| D1110 |
Prophylaxis - adult |
76 |
76 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
114 |
114 |
$1K |
| D1120 |
Prophylaxis - child |
41 |
41 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
75 |
75 |
$958.85 |
| D1206 |
Topical application of fluoride varnish |
44 |
44 |
$536.03 |
| D0230 |
Intraoral - periapical each additional radiographic image |
67 |
67 |
$407.67 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$335.50 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
12 |
$310.00 |