| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,782 |
1,782 |
$90K |
| D0120 |
Periodic oral evaluation - established patient |
1,549 |
1,549 |
$36K |
| D0272 |
Bitewings - two radiographic images |
797 |
797 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
301 |
301 |
$12K |
| D0330 |
Panoramic radiographic image |
243 |
243 |
$11K |
| D0274 |
Bitewings - four radiographic images |
270 |
270 |
$6K |
| D1120 |
Prophylaxis - child |
71 |
71 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
187 |
180 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
57 |
50 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
75 |
71 |
$575.14 |
| D1208 |
Topical application of fluoride, excluding varnish |
24 |
24 |
$392.40 |