| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
311 |
310 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
273 |
273 |
$7K |
| D1206 |
Topical application of fluoride varnish |
189 |
189 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
182 |
181 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
258 |
255 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
50 |
50 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
148 |
146 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
66 |
65 |
$2K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$550.75 |
| D0272 |
Bitewings - two radiographic images |
26 |
26 |
$446.95 |