| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
271 |
271 |
$19K |
| D1110 |
Prophylaxis - adult |
161 |
161 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
79 |
79 |
$5K |
| D0330 |
Panoramic radiographic image |
38 |
38 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
41 |
38 |
$710.61 |
| D0274 |
Bitewings - four radiographic images |
134 |
134 |
$162.00 |
| D1351 |
Sealant - per tooth |
378 |
121 |
$151.60 |
| D0120 |
Periodic oral evaluation - established patient |
342 |
342 |
$71.34 |
| D0240 |
|
131 |
67 |
$49.05 |
| D0220 |
Intraoral - periapical first radiographic image |
154 |
148 |
$38.67 |
| D1206 |
Topical application of fluoride varnish |
421 |
421 |
$16.35 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
12 |
$0.00 |
| D0601 |
|
117 |
117 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
120 |
97 |
$0.00 |
| D1330 |
|
434 |
434 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
208 |
208 |
$0.00 |
| D0603 |
|
14 |
14 |
$0.00 |