| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
178 |
171 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
52 |
31 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
14 |
$839.83 |
| D0274 |
Bitewings - four radiographic images |
155 |
148 |
$534.22 |
| D1110 |
Prophylaxis - adult |
147 |
140 |
$77.85 |
| D1208 |
Topical application of fluoride, excluding varnish |
198 |
191 |
$0.00 |
| D1330 |
|
108 |
106 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$0.00 |
| D1120 |
Prophylaxis - child |
38 |
37 |
$0.00 |