| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,081 |
1,081 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
2,006 |
2,006 |
$47K |
| D1120 |
Prophylaxis - child |
881 |
881 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,388 |
1,388 |
$23K |
| D0272 |
Bitewings - two radiographic images |
203 |
203 |
$4K |
| D0274 |
Bitewings - four radiographic images |
112 |
112 |
$3K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$651.17 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$486.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
13 |
$455.00 |