| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
211 |
210 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
379 |
378 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
109 |
68 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
228 |
227 |
$6K |
| D0274 |
Bitewings - four radiographic images |
254 |
254 |
$3K |
| D1110 |
Prophylaxis - adult |
61 |
61 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
45 |
28 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
359 |
359 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
296 |
296 |
$924.00 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$375.00 |