| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
394 |
393 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
463 |
462 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
54 |
28 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
292 |
292 |
$6K |
| D1110 |
Prophylaxis - adult |
94 |
94 |
$5K |
| D1206 |
Topical application of fluoride varnish |
179 |
178 |
$3K |
| D0274 |
Bitewings - four radiographic images |
67 |
67 |
$2K |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$375.00 |