| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1208 |
Topical application of fluoride, excluding varnish |
115 |
94 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
42 |
15 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
51 |
34 |
$700.26 |
| D0274 |
Bitewings - four radiographic images |
40 |
29 |
$513.93 |
| D0210 |
Intraoral - complete series of radiographic images |
23 |
12 |
$480.41 |
| D1110 |
Prophylaxis - adult |
29 |
16 |
$432.39 |
| D1120 |
Prophylaxis - child |
24 |
15 |
$327.30 |
| D0120 |
Periodic oral evaluation - established patient |
22 |
14 |
$206.20 |
| D0220 |
Intraoral - periapical first radiographic image |
21 |
13 |
$102.72 |