| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
376 |
376 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
370 |
370 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
401 |
401 |
$10K |
| D0272 |
Bitewings - two radiographic images |
91 |
91 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
12 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
14 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
94 |
94 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
19 |
19 |
$228.00 |