| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
662 |
653 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
283 |
169 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
742 |
734 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
211 |
134 |
$10K |
| D0274 |
Bitewings - four radiographic images |
289 |
284 |
$8K |
| D1206 |
Topical application of fluoride varnish |
400 |
398 |
$7K |
| D1120 |
Prophylaxis - child |
13 |
13 |
$411.00 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$115.35 |