| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,093 |
1,037 |
$57K |
| D0120 |
Periodic oral evaluation - established patient |
1,283 |
1,214 |
$54K |
| D1206 |
Topical application of fluoride varnish |
1,437 |
1,363 |
$46K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
148 |
86 |
$33K |
| D1110 |
Prophylaxis - adult |
324 |
309 |
$23K |
| D0272 |
Bitewings - two radiographic images |
629 |
592 |
$22K |
| D1351 |
Sealant - per tooth |
94 |
27 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
12 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
56 |
51 |
$3K |
| D0274 |
Bitewings - four radiographic images |
16 |
16 |
$753.35 |
| D0603 |
|
1,329 |
1,265 |
$0.00 |