| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
550 |
543 |
$11K |
| D1110 |
Prophylaxis - adult |
175 |
174 |
$9K |
| D1120 |
Prophylaxis - child |
224 |
220 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
180 |
180 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
134 |
81 |
$5K |
| D0330 |
Panoramic radiographic image |
69 |
69 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
15 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
13 |
$2K |