| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
138 |
138 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
112 |
112 |
$3K |
| D1120 |
Prophylaxis - child |
143 |
141 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
158 |
156 |
$3K |
| D1206 |
Topical application of fluoride varnish |
164 |
162 |
$3K |
| D0330 |
Panoramic radiographic image |
26 |
26 |
$1K |
| D0274 |
Bitewings - four radiographic images |
91 |
90 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
13 |
$860.32 |
| D0272 |
Bitewings - two radiographic images |
16 |
15 |
$157.50 |