| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
89 |
88 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
35 |
12 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
76 |
76 |
$2K |
| D1110 |
Prophylaxis - adult |
45 |
44 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
89 |
88 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
29 |
28 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$782.21 |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$471.46 |