| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,126 |
2,104 |
$72K |
| D0120 |
Periodic oral evaluation - established patient |
2,369 |
2,339 |
$58K |
| D1206 |
Topical application of fluoride varnish |
2,478 |
2,453 |
$51K |
| D0272 |
Bitewings - two radiographic images |
662 |
656 |
$14K |
| D1110 |
Prophylaxis - adult |
105 |
100 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
101 |
98 |
$1K |
| D1351 |
Sealant - per tooth |
42 |
12 |
$745.66 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$647.73 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$400.42 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$143.47 |