| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
469 |
462 |
$13K |
| D1120 |
Prophylaxis - child |
302 |
298 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
623 |
616 |
$9K |
| D1351 |
Sealant - per tooth |
292 |
62 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
774 |
488 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
538 |
523 |
$6K |
| D1110 |
Prophylaxis - adult |
90 |
89 |
$5K |
| D0274 |
Bitewings - four radiographic images |
139 |
136 |
$4K |
| D0350 |
|
312 |
303 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
25 |
25 |
$883.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
33 |
26 |
$759.08 |
| D0272 |
Bitewings - two radiographic images |
33 |
30 |
$701.40 |
| D0601 |
|
100 |
99 |
$0.00 |
| D0602 |
|
183 |
183 |
$0.00 |
| D0603 |
|
26 |
25 |
$0.00 |
| D1330 |
|
16 |
16 |
$0.00 |