| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
66 |
66 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
12 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
52 |
52 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$882.48 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
16 |
$539.78 |
| D1120 |
Prophylaxis - child |
14 |
14 |
$533.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
15 |
$350.00 |
| D0220 |
Intraoral - periapical first radiographic image |
16 |
14 |
$207.26 |