| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,108 |
4,108 |
$222K |
| D0120 |
Periodic oral evaluation - established patient |
6,922 |
6,922 |
$189K |
| D1120 |
Prophylaxis - child |
2,237 |
2,237 |
$95K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,096 |
3,096 |
$43K |
| D0274 |
Bitewings - four radiographic images |
1,124 |
1,124 |
$31K |
| D0330 |
Panoramic radiographic image |
357 |
357 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
108 |
101 |
$9K |
| D1351 |
Sealant - per tooth |
18 |
14 |
$3K |
| D9110 |
|
75 |
74 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
13 |
$775.50 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$381.64 |