| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
930 |
864 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
1,260 |
1,159 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
212 |
126 |
$12K |
| D0274 |
Bitewings - four radiographic images |
466 |
437 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
602 |
547 |
$8K |
| D1120 |
Prophylaxis - child |
244 |
219 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
41 |
26 |
$2K |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$136.50 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$63.00 |