| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
630 |
627 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
725 |
721 |
$24K |
| D1206 |
Topical application of fluoride varnish |
360 |
359 |
$11K |
| D0274 |
Bitewings - four radiographic images |
240 |
238 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
12 |
$2K |
| D1120 |
Prophylaxis - child |
56 |
56 |
$2K |
| D0330 |
Panoramic radiographic image |
19 |
19 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$168.41 |