| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
276 |
249 |
$6K |
| D1351 |
Sealant - per tooth |
266 |
32 |
$5K |
| D1206 |
Topical application of fluoride varnish |
372 |
337 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
253 |
226 |
$4K |
| D0272 |
Bitewings - two radiographic images |
179 |
166 |
$3K |
| D0274 |
Bitewings - four radiographic images |
47 |
46 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
66 |
60 |
$555.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
58 |
26 |
$528.00 |
| D1110 |
Prophylaxis - adult |
15 |
14 |
$511.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
28 |
25 |
$471.00 |