| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
340 |
340 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
456 |
455 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
419 |
419 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
54 |
25 |
$5K |
| D1110 |
Prophylaxis - adult |
69 |
68 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
38 |
38 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
54 |
54 |
$892.80 |
| D0274 |
Bitewings - four radiographic images |
25 |
24 |
$797.20 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
13 |
$117.00 |