| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
406 |
406 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
169 |
148 |
$7K |
| D1206 |
Topical application of fluoride varnish |
288 |
288 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
144 |
142 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
45 |
42 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
93 |
92 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
72 |
72 |
$2K |
| D1120 |
Prophylaxis - child |
309 |
309 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
90 |
90 |
$0.00 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
28 |
28 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
32 |
32 |
$0.00 |