| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
786 |
754 |
$33K |
| D1206 |
Topical application of fluoride varnish |
688 |
658 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
424 |
408 |
$13K |
| D0274 |
Bitewings - four radiographic images |
113 |
109 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
46 |
25 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$700.70 |