| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
327 |
326 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
73 |
40 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
100 |
100 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
259 |
257 |
$6K |
| D0180 |
|
100 |
99 |
$4K |
| D0274 |
Bitewings - four radiographic images |
58 |
58 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
12 |
$2K |
| D1206 |
Topical application of fluoride varnish |
46 |
46 |
$750.50 |
| D1120 |
Prophylaxis - child |
25 |
25 |
$746.48 |