| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
62 |
62 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
15 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
61 |
61 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
31 |
31 |
$1K |
| D1206 |
Topical application of fluoride varnish |
68 |
68 |
$1K |
| D0272 |
Bitewings - two radiographic images |
51 |
51 |
$965.94 |
| D1120 |
Prophylaxis - child |
18 |
18 |
$626.40 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$500.50 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$153.96 |