| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1208 |
Topical application of fluoride, excluding varnish |
922 |
912 |
$12K |
| D1110 |
Prophylaxis - adult |
360 |
355 |
$10K |
| D1120 |
Prophylaxis - child |
453 |
449 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
727 |
721 |
$9K |
| D0274 |
Bitewings - four radiographic images |
393 |
388 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
725 |
371 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
12 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
460 |
452 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
40 |
26 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$488.40 |