| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1208 |
Topical application of fluoride, excluding varnish |
916 |
900 |
$21K |
| D1110 |
Prophylaxis - adult |
256 |
255 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
521 |
511 |
$16K |
| D1120 |
Prophylaxis - child |
255 |
248 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
79 |
39 |
$11K |
| D0274 |
Bitewings - four radiographic images |
386 |
379 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
150 |
149 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
12 |
$3K |
| D1330 |
|
263 |
260 |
$2K |
| D0330 |
Panoramic radiographic image |
26 |
26 |
$1K |
| D0272 |
Bitewings - two radiographic images |
34 |
34 |
$532.56 |