| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
48 |
27 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
52 |
25 |
$7K |
| D1120 |
Prophylaxis - child |
91 |
91 |
$3K |
| D1206 |
Topical application of fluoride varnish |
82 |
82 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
46 |
46 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$585.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$204.00 |