| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
868 |
868 |
$39K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
254 |
138 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
628 |
628 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
475 |
475 |
$8K |
| D0274 |
Bitewings - four radiographic images |
165 |
165 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
37 |
24 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
83 |
83 |
$3K |
| D1120 |
Prophylaxis - child |
25 |
25 |
$870.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$246.22 |