| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
537 |
520 |
$10K |
| D1206 |
Topical application of fluoride varnish |
693 |
671 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
473 |
453 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
197 |
197 |
$4K |
| D1110 |
Prophylaxis - adult |
56 |
51 |
$2K |
| D9920 |
|
36 |
36 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
84 |
84 |
$984.20 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$797.20 |
| D0220 |
Intraoral - periapical first radiographic image |
115 |
115 |
$711.97 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$430.56 |
| D0240 |
|
23 |
12 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
72 |
29 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$0.00 |