| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
143 |
143 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
175 |
175 |
$3K |
| D1206 |
Topical application of fluoride varnish |
147 |
147 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
13 |
$2K |
| D0274 |
Bitewings - four radiographic images |
47 |
47 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
31 |
31 |
$623.70 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$435.76 |
| D0220 |
Intraoral - periapical first radiographic image |
18 |
17 |
$201.24 |
| D0230 |
Intraoral - periapical each additional radiographic image |
16 |
15 |
$178.88 |