| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
575 |
565 |
$24K |
| D1206 |
Topical application of fluoride varnish |
174 |
172 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
257 |
245 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
169 |
169 |
$5K |
| D1110 |
Prophylaxis - adult |
98 |
98 |
$4K |
| D0274 |
Bitewings - four radiographic images |
108 |
99 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
12 |
$990.00 |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$450.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$420.00 |