| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,349 |
2,297 |
$59K |
| D1120 |
Prophylaxis - child |
1,890 |
1,846 |
$42K |
| D1206 |
Topical application of fluoride varnish |
2,459 |
2,407 |
$35K |
| D0272 |
Bitewings - two radiographic images |
1,083 |
1,063 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
213 |
169 |
$15K |
| D1110 |
Prophylaxis - adult |
331 |
329 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
170 |
125 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
39 |
35 |
$924.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$474.00 |