| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
317 |
316 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
136 |
80 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
383 |
381 |
$8K |
| D0274 |
Bitewings - four radiographic images |
199 |
198 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
48 |
36 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
155 |
154 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
27 |
27 |
$505.44 |
| D9110 |
|
16 |
16 |
$480.00 |