| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1208 |
Topical application of fluoride, excluding varnish |
1,932 |
1,929 |
$34K |
| D1110 |
Prophylaxis - adult |
676 |
676 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
1,416 |
1,414 |
$25K |
| D1120 |
Prophylaxis - child |
740 |
738 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
207 |
161 |
$13K |
| D0274 |
Bitewings - four radiographic images |
357 |
357 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
62 |
50 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$375.72 |