| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
578 |
578 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
661 |
661 |
$16K |
| D1206 |
Topical application of fluoride varnish |
248 |
248 |
$7K |
| D1110 |
Prophylaxis - adult |
129 |
129 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
394 |
394 |
$5K |
| D0272 |
Bitewings - two radiographic images |
178 |
178 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
13 |
$855.00 |
| D0274 |
Bitewings - four radiographic images |
28 |
28 |
$691.60 |
| D0220 |
Intraoral - periapical first radiographic image |
26 |
26 |
$291.65 |