| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
427 |
427 |
$31K |
| D1120 |
Prophylaxis - child |
251 |
251 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
216 |
96 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
459 |
459 |
$570.09 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
14 |
$423.38 |
| D0274 |
Bitewings - four radiographic images |
166 |
166 |
$294.68 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
53 |
53 |
$195.53 |
| D0120 |
Periodic oral evaluation - established patient |
665 |
665 |
$92.83 |
| D0272 |
Bitewings - two radiographic images |
144 |
144 |
$0.00 |