| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
220 |
212 |
$7K |
| D0145 |
Oral evaluation for a patient under three years of age |
55 |
54 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
586 |
227 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
187 |
182 |
$5K |
| D1351 |
Sealant - per tooth |
149 |
38 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
265 |
248 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
127 |
123 |
$2K |
| D0272 |
Bitewings - two radiographic images |
40 |
40 |
$825.69 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$632.55 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
12 |
$388.52 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
12 |
12 |
$325.32 |
| D1206 |
Topical application of fluoride varnish |
27 |
26 |
$308.70 |
| D0603 |
|
342 |
336 |
$0.00 |