| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
1,006 |
209 |
$26K |
| D1120 |
Prophylaxis - child |
493 |
489 |
$17K |
| D0145 |
Oral evaluation for a patient under three years of age |
116 |
116 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
461 |
455 |
$13K |
| D0272 |
Bitewings - two radiographic images |
482 |
477 |
$11K |
| D1206 |
Topical application of fluoride varnish |
514 |
510 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
510 |
504 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
498 |
493 |
$6K |
| D1110 |
Prophylaxis - adult |
20 |
20 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
26 |
$918.32 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
15 |
15 |
$406.65 |
| D0603 |
|
713 |
704 |
$0.00 |
| D0601 |
|
23 |
22 |
$0.00 |