| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
379 |
377 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
434 |
432 |
$3K |
| D0272 |
Bitewings - two radiographic images |
196 |
196 |
$2K |
| D0330 |
Panoramic radiographic image |
35 |
34 |
$830.15 |
| D0145 |
Oral evaluation for a patient under three years of age |
62 |
61 |
$575.00 |
| D0274 |
Bitewings - four radiographic images |
63 |
63 |
$521.27 |
| D1351 |
Sealant - per tooth |
208 |
55 |
$494.36 |
| D0120 |
Periodic oral evaluation - established patient |
156 |
155 |
$118.50 |
| D1110 |
Prophylaxis - adult |
41 |
41 |
$113.12 |
| D0230 |
Intraoral - periapical each additional radiographic image |
60 |
41 |
$58.82 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
54 |
51 |
$54.71 |
| D0220 |
Intraoral - periapical first radiographic image |
73 |
72 |
$51.62 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
17 |
17 |
$36.47 |
| D0350 |
|
15 |
14 |
$18.72 |
| D0603 |
|
241 |
239 |
$0.00 |