| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,058 |
980 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
926 |
858 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
957 |
884 |
$23K |
| D1206 |
Topical application of fluoride varnish |
100 |
95 |
$2K |
| D0272 |
Bitewings - two radiographic images |
212 |
186 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
84 |
77 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
12 |
12 |
$840.00 |
| D1351 |
Sealant - per tooth |
27 |
12 |
$612.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$226.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$202.80 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
12 |
$72.71 |
| D0601 |
|
25 |
25 |
$0.00 |