| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
45 |
45 |
$2K |
| D1110 |
Prophylaxis - adult |
38 |
38 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
13 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
12 |
$354.78 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
180 |
180 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
164 |
164 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
27 |
27 |
$0.00 |