| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
417 |
417 |
$20K |
| D1206 |
Topical application of fluoride varnish |
365 |
364 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
209 |
209 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
69 |
69 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
120 |
118 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
46 |
46 |
$864.00 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$560.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
12 |
12 |
$552.00 |