| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
604 |
576 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
736 |
700 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
205 |
187 |
$5K |
| D0274 |
Bitewings - four radiographic images |
156 |
142 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
13 |
13 |
$722.25 |
| D0220 |
Intraoral - periapical first radiographic image |
83 |
81 |
$461.22 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$327.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
24 |
24 |
$91.20 |