| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
240 |
225 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
445 |
421 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
308 |
280 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
143 |
130 |
$5K |
| D1110 |
Prophylaxis - adult |
83 |
80 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
112 |
107 |
$3K |
| D0274 |
Bitewings - four radiographic images |
108 |
103 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
157 |
143 |
$2K |
| D0330 |
Panoramic radiographic image |
34 |
27 |
$873.20 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
12 |
12 |
$471.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
17 |
12 |
$159.00 |