| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,567 |
3,526 |
$150K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,097 |
5,931 |
$123K |
| D1120 |
Prophylaxis - child |
2,281 |
2,233 |
$75K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
818 |
499 |
$59K |
| D0120 |
Periodic oral evaluation - established patient |
2,582 |
2,503 |
$58K |
| D0330 |
Panoramic radiographic image |
734 |
705 |
$33K |
| D0274 |
Bitewings - four radiographic images |
1,016 |
992 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
503 |
488 |
$14K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
186 |
151 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
55 |
38 |
$4K |
| D1351 |
Sealant - per tooth |
63 |
12 |
$2K |