| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
821 |
820 |
$23K |
| D1110 |
Prophylaxis - adult |
401 |
400 |
$18K |
| D1206 |
Topical application of fluoride varnish |
359 |
358 |
$8K |
| D0274 |
Bitewings - four radiographic images |
137 |
137 |
$4K |
| D1120 |
Prophylaxis - child |
115 |
114 |
$4K |
| D0330 |
Panoramic radiographic image |
18 |
17 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
26 |
$653.92 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$337.03 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13 |
12 |
$145.40 |