| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,061 |
1,061 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
1,347 |
1,347 |
$30K |
| D0274 |
Bitewings - four radiographic images |
307 |
307 |
$8K |
| D1120 |
Prophylaxis - child |
179 |
179 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
62 |
43 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
255 |
255 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
29 |
24 |
$3K |
| D0330 |
Panoramic radiographic image |
40 |
40 |
$2K |
| D0272 |
Bitewings - two radiographic images |
102 |
102 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$153.96 |