| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
317 |
312 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
352 |
347 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
236 |
228 |
$4K |
| D1206 |
Topical application of fluoride varnish |
189 |
189 |
$4K |
| D0272 |
Bitewings - two radiographic images |
122 |
120 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
36 |
35 |
$910.00 |
| D1110 |
Prophylaxis - adult |
18 |
18 |
$865.80 |
| D0330 |
Panoramic radiographic image |
18 |
18 |
$702.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
26 |
24 |
$663.00 |