| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
796 |
796 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
1,070 |
1,069 |
$29K |
| D0274 |
Bitewings - four radiographic images |
373 |
373 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
97 |
54 |
$7K |
| D0330 |
Panoramic radiographic image |
65 |
65 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
12 |
$1K |
| D1120 |
Prophylaxis - child |
28 |
28 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
55 |
55 |
$745.50 |