| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
256 |
254 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
260 |
258 |
$5K |
| D1206 |
Topical application of fluoride varnish |
301 |
299 |
$5K |
| D0272 |
Bitewings - two radiographic images |
124 |
123 |
$2K |
| D1351 |
Sealant - per tooth |
96 |
29 |
$2K |
| D1110 |
Prophylaxis - adult |
51 |
51 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
45 |
44 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
53 |
52 |
$933.24 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
24 |
24 |
$846.02 |
| D0240 |
|
43 |
42 |
$576.92 |
| D1354 |
|
49 |
15 |
$137.26 |