| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
805 |
805 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
945 |
945 |
$28K |
| D1206 |
Topical application of fluoride varnish |
809 |
808 |
$25K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
411 |
362 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
76 |
76 |
$2K |
| D0330 |
Panoramic radiographic image |
31 |
31 |
$2K |
| D0272 |
Bitewings - two radiographic images |
108 |
108 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
121 |
119 |
$903.00 |
| D0602 |
|
55 |
55 |
$490.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
38 |
38 |
$359.00 |
| D0601 |
|
52 |
52 |
$340.00 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$315.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$264.00 |
| D1330 |
|
344 |
340 |
$0.00 |
| D1999 |
|
164 |
159 |
$0.00 |