| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,273 |
1,273 |
$62K |
| D0120 |
Periodic oral evaluation - established patient |
2,457 |
2,457 |
$56K |
| D1120 |
Prophylaxis - child |
1,144 |
1,144 |
$39K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,231 |
2,231 |
$36K |
| D0274 |
Bitewings - four radiographic images |
964 |
964 |
$26K |
| D0330 |
Panoramic radiographic image |
187 |
187 |
$9K |
| D1351 |
Sealant - per tooth |
231 |
76 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
51 |
30 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
80 |
74 |
$3K |
| D0272 |
Bitewings - two radiographic images |
135 |
135 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
32 |
25 |
$2K |