| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
33 |
13 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
102 |
99 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
153 |
148 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
118 |
113 |
$1K |
| D1120 |
Prophylaxis - child |
39 |
39 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
88 |
87 |
$966.84 |
| D0274 |
Bitewings - four radiographic images |
19 |
19 |
$620.69 |
| D0603 |
|
120 |
117 |
$0.00 |