| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
264 |
256 |
$13K |
| D1351 |
Sealant - per tooth |
487 |
72 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
848 |
834 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
412 |
404 |
$11K |
| D1120 |
Prophylaxis - child |
247 |
241 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
181 |
178 |
$6K |
| D0330 |
Panoramic radiographic image |
103 |
101 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
13 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
34 |
34 |
$1K |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$327.32 |
| D0602 |
|
309 |
305 |
$0.00 |
| D0603 |
|
493 |
486 |
$0.00 |