| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
570 |
404 |
$26K |
| D1206 |
Topical application of fluoride varnish |
957 |
944 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
601 |
592 |
$18K |
| D1110 |
Prophylaxis - adult |
283 |
281 |
$18K |
| D1120 |
Prophylaxis - child |
94 |
94 |
$4K |
| D0274 |
Bitewings - four radiographic images |
165 |
164 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
13 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$2K |
| D1330 |
|
208 |
203 |
$1K |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
16 |
$901.44 |