| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
720 |
720 |
$37K |
| D1310 |
|
469 |
469 |
$21K |
| D1206 |
Topical application of fluoride varnish |
713 |
713 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
238 |
238 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
239 |
239 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,272 |
476 |
$9K |
| D0145 |
Oral evaluation for a patient under three years of age |
131 |
131 |
$8K |
| D0603 |
|
467 |
467 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
326 |
316 |
$4K |
| D1351 |
Sealant - per tooth |
59 |
14 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
42 |
40 |
$2K |
| D0350 |
|
113 |
40 |
$1K |
| D0272 |
Bitewings - two radiographic images |
49 |
49 |
$576.00 |