| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
51 |
51 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
12 |
$978.19 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
12 |
$935.64 |
| D0120 |
Periodic oral evaluation - established patient |
46 |
46 |
$850.50 |
| D0274 |
Bitewings - four radiographic images |
27 |
27 |
$687.96 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$207.90 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$90.72 |