| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
3,390 |
421 |
$91K |
| D1120 |
Prophylaxis - child |
855 |
817 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,246 |
1,183 |
$22K |
| D1110 |
Prophylaxis - adult |
413 |
399 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
793 |
749 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
376 |
361 |
$11K |
| D0330 |
Panoramic radiographic image |
170 |
166 |
$9K |
| D0274 |
Bitewings - four radiographic images |
159 |
155 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
58 |
25 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
12 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
51 |
44 |
$2K |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$221.00 |