| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
647 |
572 |
$26K |
| D1206 |
Topical application of fluoride varnish |
563 |
490 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
386 |
309 |
$9K |
| D0272 |
Bitewings - two radiographic images |
460 |
407 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
324 |
302 |
$6K |
| D0240 |
|
455 |
289 |
$5K |
| D0330 |
Panoramic radiographic image |
91 |
72 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
277 |
246 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
137 |
112 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
338 |
260 |
$2K |
| D0603 |
|
494 |
410 |
$1K |
| D1110 |
Prophylaxis - adult |
15 |
12 |
$499.81 |
| D0274 |
Bitewings - four radiographic images |
18 |
18 |
$424.26 |
| D1208 |
Topical application of fluoride, excluding varnish |
19 |
19 |
$194.56 |
| D9986 |
|
28 |
27 |
$0.00 |