| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
589 |
510 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
1,048 |
940 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
982 |
868 |
$21K |
| D0274 |
Bitewings - four radiographic images |
382 |
352 |
$13K |
| D1120 |
Prophylaxis - child |
102 |
97 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
12 |
$2K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$884.84 |
| D4910 |
|
24 |
13 |
$875.55 |
| D0272 |
Bitewings - two radiographic images |
32 |
28 |
$619.02 |