| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
559 |
554 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
705 |
699 |
$15K |
| D1206 |
Topical application of fluoride varnish |
726 |
720 |
$13K |
| D1110 |
Prophylaxis - adult |
186 |
184 |
$8K |
| D0272 |
Bitewings - two radiographic images |
280 |
279 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
128 |
121 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
44 |
42 |
$688.79 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$595.95 |
| D0230 |
Intraoral - periapical each additional radiographic image |
30 |
14 |
$200.25 |