| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,986 |
7,777 |
$244K |
| D0120 |
Periodic oral evaluation - established patient |
10,186 |
9,921 |
$219K |
| D1206 |
Topical application of fluoride varnish |
10,254 |
9,971 |
$181K |
| D1351 |
Sealant - per tooth |
5,638 |
1,590 |
$136K |
| D1110 |
Prophylaxis - adult |
2,214 |
2,159 |
$90K |
| D0272 |
Bitewings - two radiographic images |
3,954 |
3,867 |
$81K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,391 |
1,308 |
$39K |
| D0274 |
Bitewings - four radiographic images |
709 |
692 |
$21K |
| D1354 |
|
1,005 |
317 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
683 |
645 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
34 |
13 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
15 |
$1K |
| D0330 |
Panoramic radiographic image |
26 |
24 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
62 |
36 |
$658.90 |
| D0240 |
|
12 |
12 |
$190.80 |