| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
67 |
67 |
$6K |
| D4910 |
|
69 |
69 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
76 |
76 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
156 |
152 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
28 |
28 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
24 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$624.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$148.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$146.00 |