| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,005 |
994 |
$34K |
| D0145 |
Oral evaluation for a patient under three years of age |
176 |
176 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
854 |
837 |
$23K |
| D1110 |
Prophylaxis - adult |
317 |
312 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
159 |
57 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
674 |
665 |
$10K |
| D1206 |
Topical application of fluoride varnish |
643 |
635 |
$9K |
| D0272 |
Bitewings - two radiographic images |
362 |
362 |
$8K |
| D0274 |
Bitewings - four radiographic images |
222 |
215 |
$6K |
| D0330 |
Panoramic radiographic image |
59 |
57 |
$3K |
| D1351 |
Sealant - per tooth |
62 |
14 |
$2K |
| D0603 |
|
1,144 |
1,118 |
$0.00 |
| D0602 |
|
12 |
12 |
$0.00 |