| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
803 |
801 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
436 |
432 |
$24K |
| D1206 |
Topical application of fluoride varnish |
901 |
898 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
425 |
425 |
$13K |
| D1351 |
Sealant - per tooth |
110 |
26 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
180 |
151 |
$3K |
| D0272 |
Bitewings - two radiographic images |
212 |
211 |
$3K |
| D1330 |
|
382 |
382 |
$3K |
| D0330 |
Panoramic radiographic image |
38 |
38 |
$2K |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$872.56 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$288.84 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$141.84 |