| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,714 |
1,641 |
$101K |
| D0120 |
Periodic oral evaluation - established patient |
3,617 |
3,515 |
$98K |
| D1120 |
Prophylaxis - child |
1,883 |
1,841 |
$94K |
| D9450 |
|
2,747 |
2,354 |
$58K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,249 |
1,229 |
$36K |
| D1206 |
Topical application of fluoride varnish |
326 |
318 |
$8K |
| D0274 |
Bitewings - four radiographic images |
129 |
122 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
41 |
25 |
$3K |
| D0272 |
Bitewings - two radiographic images |
42 |
42 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$1K |