| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
461 |
461 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
515 |
514 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
698 |
697 |
$10K |
| D0272 |
Bitewings - two radiographic images |
308 |
308 |
$7K |
| D1110 |
Prophylaxis - adult |
107 |
106 |
$6K |
| D0274 |
Bitewings - four radiographic images |
130 |
129 |
$4K |
| D0240 |
|
322 |
144 |
$3K |
| D1351 |
Sealant - per tooth |
101 |
27 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
36 |
36 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
74 |
74 |
$916.88 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
26 |
25 |
$677.75 |
| D0230 |
Intraoral - periapical each additional radiographic image |
31 |
29 |
$356.81 |
| D0601 |
|
258 |
255 |
$0.00 |
| D0602 |
|
54 |
54 |
$0.00 |
| D0603 |
|
216 |
215 |
$0.00 |