| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
786 |
765 |
$30K |
| D1206 |
Topical application of fluoride varnish |
785 |
764 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
701 |
682 |
$18K |
| D8670 |
Periodic orthodontic treatment visit |
53 |
53 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
319 |
311 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
294 |
279 |
$1K |
| D1351 |
Sealant - per tooth |
22 |
14 |
$1K |
| D8999 |
|
25 |
25 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
26 |
25 |
$650.00 |
| D0274 |
Bitewings - four radiographic images |
40 |
40 |
$625.30 |
| D0272 |
Bitewings - two radiographic images |
63 |
62 |
$517.00 |