| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
959 |
959 |
$33K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,017 |
1,017 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
757 |
757 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
84 |
63 |
$10K |
| D1110 |
Prophylaxis - adult |
42 |
42 |
$2K |
| D0272 |
Bitewings - two radiographic images |
67 |
67 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
45 |
45 |
$684.85 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$288.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
19 |
17 |
$155.06 |