| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
130 |
129 |
$3K |
| D1110 |
Prophylaxis - adult |
70 |
70 |
$3K |
| D1120 |
Prophylaxis - child |
81 |
80 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
58 |
50 |
$2K |
| D0272 |
Bitewings - two radiographic images |
76 |
75 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
74 |
73 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$568.44 |
| D0220 |
Intraoral - periapical first radiographic image |
32 |
29 |
$426.01 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$340.06 |