| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
351 |
351 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
483 |
483 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
56 |
52 |
$4K |
| D9110 |
|
60 |
60 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
28 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
125 |
125 |
$1K |
| D2332 |
|
12 |
12 |
$780.00 |
| D0272 |
Bitewings - two radiographic images |
38 |
38 |
$606.70 |
| D1120 |
Prophylaxis - child |
14 |
14 |
$420.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
16 |
$299.52 |