| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
281 |
275 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
97 |
97 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
34 |
25 |
$1K |
| D1120 |
Prophylaxis - child |
39 |
39 |
$606.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
13 |
$580.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$520.00 |
| D0274 |
Bitewings - four radiographic images |
27 |
26 |
$343.00 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$269.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$99.00 |