| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
331 |
331 |
$15K |
| D1206 |
Topical application of fluoride varnish |
365 |
365 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
208 |
208 |
$5K |
| D1351 |
Sealant - per tooth |
120 |
25 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
187 |
186 |
$935.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$675.00 |
| D0272 |
Bitewings - two radiographic images |
65 |
65 |
$650.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
25 |
25 |
$615.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
126 |
126 |
$423.00 |
| D0603 |
|
13 |
13 |
$130.00 |
| D0601 |
|
12 |
12 |
$120.00 |