| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
728 |
722 |
$17K |
| D1120 |
Prophylaxis - child |
435 |
434 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
576 |
576 |
$14K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
133 |
123 |
$7K |
| D0272 |
Bitewings - two radiographic images |
119 |
119 |
$2K |
| D1110 |
Prophylaxis - adult |
46 |
46 |
$2K |
| D0274 |
Bitewings - four radiographic images |
56 |
54 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
19 |
19 |
$475.00 |
| D0240 |
|
46 |
20 |
$450.00 |
| D1330 |
|
41 |
41 |
$410.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$95.00 |