| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
193 |
192 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
29 |
26 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
140 |
140 |
$4K |
| D0350 |
|
360 |
356 |
$3K |
| D0274 |
Bitewings - four radiographic images |
100 |
100 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
76 |
76 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
59 |
59 |
$826.00 |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$564.00 |