| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
273 |
71 |
$7K |
| D1120 |
Prophylaxis - child |
176 |
176 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
202 |
202 |
$4K |
| D1206 |
Topical application of fluoride varnish |
247 |
247 |
$4K |
| D1110 |
Prophylaxis - adult |
70 |
70 |
$3K |
| D0272 |
Bitewings - two radiographic images |
116 |
116 |
$2K |
| D0274 |
Bitewings - four radiographic images |
68 |
68 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
51 |
46 |
$1K |
| D0330 |
Panoramic radiographic image |
31 |
31 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
18 |
18 |
$493.00 |
| D0240 |
|
14 |
12 |
$252.00 |