| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
278 |
278 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
340 |
340 |
$8K |
| D1206 |
Topical application of fluoride varnish |
280 |
280 |
$5K |
| D0272 |
Bitewings - two radiographic images |
101 |
101 |
$2K |
| D0274 |
Bitewings - four radiographic images |
48 |
48 |
$1K |
| D1110 |
Prophylaxis - adult |
36 |
36 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
31 |
31 |
$514.91 |
| D0220 |
Intraoral - periapical first radiographic image |
29 |
29 |
$377.08 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
16 |
16 |
$367.28 |