| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
283 |
281 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
261 |
260 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
53 |
28 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
95 |
93 |
$2K |
| D0274 |
Bitewings - four radiographic images |
77 |
77 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
30 |
14 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
31 |
31 |
$580.32 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$390.00 |
| D0220 |
Intraoral - periapical first radiographic image |
16 |
16 |
$120.00 |