| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
250 |
249 |
$13K |
| D1206 |
Topical application of fluoride varnish |
244 |
243 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
146 |
145 |
$4K |
| D0272 |
Bitewings - two radiographic images |
97 |
97 |
$2K |
| D0330 |
Panoramic radiographic image |
40 |
40 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
44 |
44 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
66 |
66 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
68 |
63 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
164 |
74 |
$889.39 |
| D1351 |
Sealant - per tooth |
71 |
12 |
$872.09 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$282.84 |