| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
225 |
224 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
269 |
269 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
153 |
152 |
$4K |
| D0274 |
Bitewings - four radiographic images |
77 |
77 |
$2K |
| D1351 |
Sealant - per tooth |
58 |
14 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
67 |
67 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
47 |
40 |
$1K |
| D0330 |
Panoramic radiographic image |
37 |
37 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
29 |
29 |
$707.60 |
| D1120 |
Prophylaxis - child |
14 |
14 |
$461.37 |
| D0220 |
Intraoral - periapical first radiographic image |
28 |
28 |
$358.68 |