| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
604 |
559 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
517 |
471 |
$11K |
| D0274 |
Bitewings - four radiographic images |
256 |
232 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
12 |
$2K |
| D0330 |
Panoramic radiographic image |
29 |
24 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
65 |
64 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$704.94 |
| D1999 |
|
118 |
109 |
$34.00 |