| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
133 |
133 |
$4K |
| D1120 |
Prophylaxis - child |
122 |
122 |
$3K |
| D1351 |
Sealant - per tooth |
135 |
32 |
$3K |
| D0330 |
Panoramic radiographic image |
46 |
46 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
207 |
174 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
28 |
26 |
$2K |
| D1330 |
|
177 |
177 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
101 |
101 |
$2K |
| D0272 |
Bitewings - two radiographic images |
116 |
116 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
139 |
138 |
$2K |
| D1110 |
Prophylaxis - adult |
51 |
51 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
44 |
44 |
$1K |
| D1206 |
Topical application of fluoride varnish |
68 |
68 |
$1K |
| D9920 |
|
32 |
32 |
$1K |
| D0274 |
Bitewings - four radiographic images |
53 |
53 |
$879.34 |