| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,342 |
1,237 |
$38K |
| D1120 |
Prophylaxis - child |
1,229 |
1,137 |
$38K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,015 |
945 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
784 |
715 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
682 |
583 |
$9K |
| D1351 |
Sealant - per tooth |
209 |
56 |
$6K |
| D0272 |
Bitewings - two radiographic images |
237 |
225 |
$5K |
| D1110 |
Prophylaxis - adult |
50 |
50 |
$3K |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
12 |
12 |
$275.00 |
| D1206 |
Topical application of fluoride varnish |
13 |
12 |
$240.00 |