| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
105 |
105 |
$3K |
| D1120 |
Prophylaxis - child |
125 |
125 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
133 |
133 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
103 |
103 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
13 |
$980.67 |
| D0274 |
Bitewings - four radiographic images |
31 |
31 |
$609.00 |
| D0272 |
Bitewings - two radiographic images |
38 |
38 |
$381.50 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$380.56 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$61.25 |