| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
278 |
278 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
97 |
55 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
190 |
190 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
153 |
153 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
66 |
42 |
$4K |
| D1120 |
Prophylaxis - child |
52 |
52 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
45 |
45 |
$2K |
| D0274 |
Bitewings - four radiographic images |
108 |
108 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$325.00 |