| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
596 |
556 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
906 |
861 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
252 |
174 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
237 |
157 |
$12K |
| D0274 |
Bitewings - four radiographic images |
219 |
206 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
221 |
212 |
$3K |
| D1120 |
Prophylaxis - child |
156 |
151 |
$3K |
| D0330 |
Panoramic radiographic image |
65 |
60 |
$2K |
| D1206 |
Topical application of fluoride varnish |
97 |
94 |
$1K |
| D0272 |
Bitewings - two radiographic images |
45 |
44 |
$451.50 |
| D0220 |
Intraoral - periapical first radiographic image |
43 |
38 |
$155.25 |