| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
327 |
327 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
87 |
56 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
340 |
340 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
139 |
139 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
43 |
28 |
$4K |
| D0274 |
Bitewings - four radiographic images |
143 |
143 |
$4K |
| D1206 |
Topical application of fluoride varnish |
123 |
123 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
22 |
22 |
$2K |
| D1120 |
Prophylaxis - child |
43 |
43 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
34 |
33 |
$404.60 |