| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,780 |
1,780 |
$81K |
| D0120 |
Periodic oral evaluation - established patient |
1,853 |
1,853 |
$74K |
| D1206 |
Topical application of fluoride varnish |
1,215 |
1,215 |
$39K |
| D0272 |
Bitewings - two radiographic images |
725 |
723 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
637 |
637 |
$11K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
169 |
152 |
$9K |
| D1351 |
Sealant - per tooth |
170 |
41 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
293 |
291 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
309 |
158 |
$4K |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$649.80 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$615.60 |
| D1330 |
|
87 |
87 |
$0.00 |
| D1310 |
|
83 |
82 |
$0.00 |