| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
280 |
280 |
$9K |
| D1206 |
Topical application of fluoride varnish |
298 |
298 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
208 |
208 |
$5K |
| D0274 |
Bitewings - four radiographic images |
106 |
106 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
120 |
120 |
$3K |
| D0330 |
Panoramic radiographic image |
39 |
39 |
$2K |
| D1351 |
Sealant - per tooth |
51 |
17 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
74 |
47 |
$1K |
| D1110 |
Prophylaxis - adult |
47 |
47 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
85 |
83 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
15 |
15 |
$403.65 |
| D0272 |
Bitewings - two radiographic images |
16 |
16 |
$386.24 |