| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
217 |
213 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
107 |
81 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
293 |
286 |
$7K |
| D1120 |
Prophylaxis - child |
84 |
82 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
114 |
113 |
$3K |
| D0274 |
Bitewings - four radiographic images |
84 |
82 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
17 |
$1K |
| D2330 |
|
18 |
14 |
$1K |
| D9110 |
|
12 |
12 |
$438.00 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$420.00 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
13 |
$220.00 |