| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
305 |
301 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
790 |
327 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
274 |
270 |
$8K |
| D1351 |
Sealant - per tooth |
213 |
43 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
351 |
345 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
341 |
333 |
$4K |
| D0274 |
Bitewings - four radiographic images |
63 |
62 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
42 |
42 |
$981.96 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
27 |
26 |
$704.86 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
17 |
16 |
$565.12 |
| D0603 |
|
351 |
349 |
$0.00 |
| D0601 |
|
13 |
13 |
$0.00 |