| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
202 |
202 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
63 |
38 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
143 |
143 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
137 |
135 |
$2K |
| D1206 |
Topical application of fluoride varnish |
74 |
74 |
$1K |
| D1110 |
Prophylaxis - adult |
26 |
26 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
38 |
38 |
$842.56 |
| D0230 |
Intraoral - periapical each additional radiographic image |
87 |
86 |
$768.43 |