| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
888 |
888 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
1,852 |
1,852 |
$43K |
| D1206 |
Topical application of fluoride varnish |
2,170 |
2,170 |
$35K |
| D1120 |
Prophylaxis - child |
892 |
892 |
$31K |
| D0272 |
Bitewings - two radiographic images |
364 |
364 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
108 |
105 |
$3K |
| D0274 |
Bitewings - four radiographic images |
109 |
109 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
50 |
50 |
$615.84 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$601.08 |