| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
186 |
185 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
32 |
17 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
133 |
131 |
$2K |
| D1120 |
Prophylaxis - child |
13 |
13 |
$633.01 |
| D0120 |
Periodic oral evaluation - established patient |
116 |
115 |
$106.75 |
| D0274 |
Bitewings - four radiographic images |
59 |
59 |
$36.80 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
16 |
16 |
$0.00 |