| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
185 |
181 |
$5K |
| D1120 |
Prophylaxis - child |
135 |
133 |
$5K |
| D1206 |
Topical application of fluoride varnish |
128 |
127 |
$3K |
| D0272 |
Bitewings - two radiographic images |
106 |
102 |
$2K |
| D1110 |
Prophylaxis - adult |
43 |
43 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
92 |
86 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
92 |
81 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
29 |
24 |
$681.60 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$679.70 |
| D1208 |
Topical application of fluoride, excluding varnish |
47 |
46 |
$646.80 |
| D0603 |
|
46 |
44 |
$0.00 |
| D0602 |
|
16 |
16 |
$0.00 |