| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
51 |
51 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
12 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
43 |
43 |
$856.37 |
| D1208 |
Topical application of fluoride, excluding varnish |
28 |
28 |
$353.92 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$324.73 |
| D0120 |
Periodic oral evaluation - established patient |
19 |
19 |
$275.22 |
| D0274 |
Bitewings - four radiographic images |
16 |
16 |
$261.95 |