| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,164 |
1,149 |
$46K |
| D1206 |
Topical application of fluoride varnish |
1,370 |
1,351 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
808 |
804 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
245 |
245 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
563 |
549 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
156 |
156 |
$7K |
| D0272 |
Bitewings - two radiographic images |
162 |
162 |
$4K |
| D1354 |
|
247 |
69 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
78 |
67 |
$2K |
| D1351 |
Sealant - per tooth |
28 |
12 |
$973.62 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$530.20 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$387.30 |