| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0272 |
Bitewings - two radiographic images |
106 |
86 |
$5K |
| D0240 |
|
46 |
32 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
85 |
69 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
148 |
130 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
189 |
77 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
118 |
111 |
$2K |
| D1206 |
Topical application of fluoride varnish |
253 |
221 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
40 |
36 |
$1K |
| D1120 |
Prophylaxis - child |
148 |
126 |
$1K |
| D0274 |
Bitewings - four radiographic images |
18 |
15 |
$1K |
| D1110 |
Prophylaxis - adult |
45 |
38 |
$878.08 |
| D1330 |
|
162 |
130 |
$659.46 |
| D1351 |
Sealant - per tooth |
76 |
16 |
$237.80 |
| D0602 |
|
48 |
47 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
17 |
17 |
$0.00 |
| D0603 |
|
79 |
79 |
$0.00 |