| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
92 |
90 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
84 |
81 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
84 |
82 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$863.80 |
| D0220 |
Intraoral - periapical first radiographic image |
77 |
76 |
$408.80 |
| D0230 |
Intraoral - periapical each additional radiographic image |
70 |
68 |
$273.60 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$202.80 |