| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
909 |
909 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
975 |
975 |
$18K |
| D1206 |
Topical application of fluoride varnish |
433 |
433 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
494 |
492 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
400 |
399 |
$2K |
| D0272 |
Bitewings - two radiographic images |
139 |
139 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
51 |
51 |
$795.00 |
| D0274 |
Bitewings - four radiographic images |
38 |
38 |
$704.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
308 |
308 |
$0.00 |