| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
812 |
786 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
929 |
882 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
109 |
69 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
44 |
31 |
$2K |
| D1206 |
Topical application of fluoride varnish |
56 |
54 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
66 |
62 |
$1K |
| D1110 |
Prophylaxis - adult |
40 |
39 |
$1K |
| D0274 |
Bitewings - four radiographic images |
72 |
65 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
40 |
40 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
57 |
57 |
$923.40 |
| D0272 |
Bitewings - two radiographic images |
54 |
54 |
$521.86 |