| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
483 |
469 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
665 |
645 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
180 |
108 |
$13K |
| D1206 |
Topical application of fluoride varnish |
627 |
608 |
$12K |
| D0274 |
Bitewings - four radiographic images |
345 |
335 |
$9K |
| D1120 |
Prophylaxis - child |
207 |
200 |
$7K |
| D0330 |
Panoramic radiographic image |
55 |
54 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$730.83 |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
14 |
$152.16 |