| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
145 |
137 |
$4K |
| D1351 |
Sealant - per tooth |
20 |
20 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
92 |
86 |
$2K |
| D1206 |
Topical application of fluoride varnish |
95 |
87 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
32 |
30 |
$1K |
| D0272 |
Bitewings - two radiographic images |
85 |
80 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
64 |
63 |
$1K |
| D1330 |
|
161 |
152 |
$765.00 |
| D1310 |
|
108 |
101 |
$514.00 |
| D0603 |
|
55 |
51 |
$510.00 |
| D0601 |
|
38 |
34 |
$340.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
15 |
$300.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
17 |
12 |
$144.00 |
| D0220 |
Intraoral - periapical first radiographic image |
21 |
16 |
$128.00 |