| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
108 |
94 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
135 |
120 |
$3K |
| D1206 |
Topical application of fluoride varnish |
134 |
122 |
$2K |
| D0272 |
Bitewings - two radiographic images |
56 |
51 |
$1K |
| D0274 |
Bitewings - four radiographic images |
27 |
26 |
$727.00 |
| D0220 |
Intraoral - periapical first radiographic image |
69 |
58 |
$649.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
80 |
23 |
$580.00 |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$541.00 |
| D0330 |
Panoramic radiographic image |
15 |
14 |
$434.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
12 |
$367.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
12 |
12 |
$240.00 |