| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
1,081 |
981 |
$37K |
| D1120 |
Prophylaxis - child |
681 |
628 |
$29K |
| D1110 |
Prophylaxis - adult |
526 |
476 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
112 |
66 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
322 |
276 |
$7K |
| D0274 |
Bitewings - four radiographic images |
172 |
156 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
285 |
264 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
78 |
78 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
162 |
147 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
24 |
12 |
$720.00 |