| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
885 |
885 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
927 |
927 |
$21K |
| D1206 |
Topical application of fluoride varnish |
1,107 |
1,107 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
324 |
315 |
$8K |
| D1110 |
Prophylaxis - adult |
180 |
180 |
$7K |
| D0272 |
Bitewings - two radiographic images |
275 |
275 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
378 |
378 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
26 |
$980.72 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
16 |
15 |
$489.76 |