| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
607 |
607 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
871 |
870 |
$22K |
| D1206 |
Topical application of fluoride varnish |
841 |
840 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
551 |
548 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
424 |
424 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
53 |
53 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$1K |
| D1110 |
Prophylaxis - adult |
24 |
24 |
$1K |