| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
147 |
146 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
184 |
183 |
$3K |
| D0274 |
Bitewings - four radiographic images |
105 |
105 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
120 |
120 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
28 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
13 |
$897.68 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$180.49 |