| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
279 |
279 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
253 |
253 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
283 |
283 |
$5K |
| D1110 |
Prophylaxis - adult |
37 |
37 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
26 |
25 |
$728.00 |
| D0272 |
Bitewings - two radiographic images |
59 |
59 |
$598.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$264.00 |
| D0220 |
Intraoral - periapical first radiographic image |
49 |
48 |
$252.00 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$240.00 |