| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
757 |
755 |
$7K |
| D1120 |
Prophylaxis - child |
659 |
656 |
$6K |
| D1206 |
Topical application of fluoride varnish |
295 |
293 |
$5K |
| D0272 |
Bitewings - two radiographic images |
243 |
243 |
$1K |
| D1110 |
Prophylaxis - adult |
43 |
43 |
$954.52 |
| D1351 |
Sealant - per tooth |
466 |
114 |
$444.60 |
| D1208 |
Topical application of fluoride, excluding varnish |
368 |
368 |
$425.76 |
| D0274 |
Bitewings - four radiographic images |
37 |
37 |
$275.22 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
192 |
169 |
$152.88 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$0.00 |
| D1999 |
|
58 |
56 |
$0.00 |