| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
873 |
873 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
890 |
890 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
417 |
417 |
$15K |
| D0272 |
Bitewings - two radiographic images |
546 |
546 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
461 |
461 |
$11K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
187 |
177 |
$5K |
| D0274 |
Bitewings - four radiographic images |
119 |
119 |
$4K |
| D1351 |
Sealant - per tooth |
117 |
28 |
$3K |
| D0240 |
|
125 |
65 |
$1K |
| D1110 |
Prophylaxis - adult |
26 |
26 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
26 |
$963.39 |