| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
523 |
523 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
630 |
630 |
$17K |
| D1206 |
Topical application of fluoride varnish |
384 |
384 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
67 |
43 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
146 |
146 |
$3K |
| D1110 |
Prophylaxis - adult |
56 |
56 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
14 |
$2K |
| D0274 |
Bitewings - four radiographic images |
18 |
18 |
$595.00 |
| D0220 |
Intraoral - periapical first radiographic image |
26 |
26 |
$414.07 |