| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1208 |
Topical application of fluoride, excluding varnish |
1,301 |
1,291 |
$25K |
| D1110 |
Prophylaxis - adult |
556 |
552 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
1,177 |
1,165 |
$22K |
| D1120 |
Prophylaxis - child |
354 |
354 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
90 |
50 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
823 |
807 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
774 |
713 |
$8K |
| D0274 |
Bitewings - four radiographic images |
312 |
312 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
13 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$375.72 |