| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
129 |
129 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
151 |
151 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
170 |
170 |
$2K |
| D0272 |
Bitewings - two radiographic images |
110 |
110 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$694.45 |
| D0220 |
Intraoral - periapical first radiographic image |
66 |
66 |
$585.20 |
| D0230 |
Intraoral - periapical each additional radiographic image |
67 |
67 |
$458.85 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$330.60 |