| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,406 |
1,402 |
$52K |
| D1206 |
Topical application of fluoride varnish |
801 |
799 |
$20K |
| D0274 |
Bitewings - four radiographic images |
322 |
322 |
$15K |
| D1110 |
Prophylaxis - adult |
206 |
203 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
278 |
259 |
$12K |
| D1120 |
Prophylaxis - child |
252 |
252 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
13 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
42 |
42 |
$35.70 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
48 |
25 |
$0.00 |