| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
662 |
655 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
592 |
590 |
$16K |
| D1206 |
Topical application of fluoride varnish |
646 |
642 |
$11K |
| D0602 |
|
436 |
433 |
$3K |
| D0272 |
Bitewings - two radiographic images |
142 |
142 |
$2K |
| D1351 |
Sealant - per tooth |
48 |
14 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
39 |
36 |
$962.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
21 |
21 |
$798.00 |
| D1110 |
Prophylaxis - adult |
15 |
15 |
$658.00 |
| D0240 |
|
32 |
16 |
$480.00 |
| D0603 |
|
78 |
78 |
$451.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$420.00 |
| D0220 |
Intraoral - periapical first radiographic image |
28 |
27 |
$364.00 |