| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
538 |
538 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
782 |
782 |
$17K |
| D1120 |
Prophylaxis - child |
359 |
359 |
$12K |
| D1206 |
Topical application of fluoride varnish |
720 |
720 |
$11K |
| D0272 |
Bitewings - two radiographic images |
586 |
586 |
$11K |
| D0274 |
Bitewings - four radiographic images |
88 |
88 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
39 |
39 |
$2K |
| D1351 |
Sealant - per tooth |
48 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
83 |
81 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
27 |
24 |
$845.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$512.90 |