| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,329 |
1,326 |
$63K |
| D0120 |
Periodic oral evaluation - established patient |
1,049 |
1,049 |
$27K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
251 |
228 |
$26K |
| D1206 |
Topical application of fluoride varnish |
602 |
602 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
613 |
613 |
$15K |
| D1351 |
Sealant - per tooth |
280 |
79 |
$6K |
| D0272 |
Bitewings - two radiographic images |
317 |
316 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
403 |
402 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
67 |
67 |
$2K |
| D0603 |
|
180 |
180 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
242 |
242 |
$1K |
| D0601 |
|
13 |
13 |
$130.00 |