| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
61 |
61 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
81 |
81 |
$2K |
| D0330 |
Panoramic radiographic image |
57 |
57 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
13 |
$2K |
| D0274 |
Bitewings - four radiographic images |
24 |
24 |
$650.75 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$490.20 |
| D0120 |
Periodic oral evaluation - established patient |
12 |
12 |
$330.60 |
| D1208 |
Topical application of fluoride, excluding varnish |
17 |
17 |
$226.10 |