| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
160 |
160 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
174 |
174 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
93 |
93 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
59 |
59 |
$2K |
| D0272 |
Bitewings - two radiographic images |
92 |
92 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
28 |
28 |
$780.00 |
| D0240 |
|
31 |
27 |
$422.40 |
| D0220 |
Intraoral - periapical first radiographic image |
57 |
57 |
$331.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
26 |
12 |
$141.00 |