| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
687 |
540 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
704 |
542 |
$20K |
| D1120 |
Prophylaxis - child |
787 |
606 |
$17K |
| D1206 |
Topical application of fluoride varnish |
461 |
347 |
$7K |
| D0330 |
Panoramic radiographic image |
186 |
103 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
33 |
15 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
16 |
$2K |
| D0274 |
Bitewings - four radiographic images |
86 |
67 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
40 |
31 |
$497.51 |
| D0120 |
Periodic oral evaluation - established patient |
14 |
14 |
$355.58 |