| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
633 |
629 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
771 |
766 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
532 |
529 |
$5K |
| D0272 |
Bitewings - two radiographic images |
306 |
303 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$1K |
| D1330 |
|
748 |
744 |
$1K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$754.00 |
| D1999 |
|
26 |
26 |
$657.02 |
| D0220 |
Intraoral - periapical first radiographic image |
278 |
273 |
$534.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
131 |
131 |
$248.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
32 |
26 |
$53.30 |