| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,029 |
1,029 |
$32K |
| D1206 |
Topical application of fluoride varnish |
941 |
941 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
219 |
90 |
$19K |
| D1120 |
Prophylaxis - child |
430 |
430 |
$17K |
| D1110 |
Prophylaxis - adult |
213 |
213 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
39 |
26 |
$6K |
| D1351 |
Sealant - per tooth |
211 |
38 |
$6K |
| D0274 |
Bitewings - four radiographic images |
148 |
148 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$2K |
| D0272 |
Bitewings - two radiographic images |
40 |
40 |
$1K |
| D0603 |
|
143 |
143 |
$1K |