| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
931 |
906 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
903 |
881 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,976 |
886 |
$19K |
| D1206 |
Topical application of fluoride varnish |
1,152 |
1,117 |
$16K |
| D0145 |
Oral evaluation for a patient under three years of age |
105 |
104 |
$14K |
| D0272 |
Bitewings - two radiographic images |
570 |
556 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,014 |
982 |
$12K |
| D1351 |
Sealant - per tooth |
387 |
85 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
56 |
55 |
$4K |
| D1110 |
Prophylaxis - adult |
38 |
37 |
$2K |
| D9420 |
|
29 |
28 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
15 |
$529.80 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$380.71 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13 |
13 |
$323.24 |
| D0603 |
|
1,585 |
1,543 |
$0.00 |