| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
419 |
418 |
$21K |
| D1310 |
|
217 |
217 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
102 |
102 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
112 |
112 |
$6K |
| D1206 |
Topical application of fluoride varnish |
205 |
205 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
989 |
181 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
137 |
137 |
$2K |
| D0603 |
|
97 |
97 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
35 |
25 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
18 |
18 |
$1K |
| D0602 |
|
28 |
28 |
$420.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$144.00 |