| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1208 |
Topical application of fluoride, excluding varnish |
682 |
676 |
$13K |
| D1120 |
Prophylaxis - child |
354 |
353 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
464 |
462 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
152 |
59 |
$8K |
| D1110 |
Prophylaxis - adult |
222 |
216 |
$8K |
| D0274 |
Bitewings - four radiographic images |
226 |
212 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
54 |
27 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
119 |
117 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
199 |
193 |
$2K |
| D0330 |
Panoramic radiographic image |
24 |
23 |
$676.51 |
| D0140 |
Limited oral evaluation - problem focused |
27 |
27 |
$590.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
79 |
38 |
$541.07 |