| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,184 |
837 |
$136K |
| D0120 |
Periodic oral evaluation - established patient |
2,334 |
2,256 |
$48K |
| D1110 |
Prophylaxis - adult |
1,252 |
1,206 |
$47K |
| D1120 |
Prophylaxis - child |
1,310 |
1,266 |
$37K |
| D0330 |
Panoramic radiographic image |
681 |
655 |
$33K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,196 |
1,113 |
$28K |
| D0274 |
Bitewings - four radiographic images |
1,008 |
965 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,068 |
1,032 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
403 |
379 |
$11K |
| D1206 |
Topical application of fluoride varnish |
628 |
605 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
260 |
252 |
$7K |
| D1351 |
Sealant - per tooth |
72 |
12 |
$2K |