| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
251 |
251 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
317 |
317 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
45 |
32 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
154 |
154 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
199 |
197 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
30 |
13 |
$3K |
| D1206 |
Topical application of fluoride varnish |
112 |
112 |
$3K |
| D1110 |
Prophylaxis - adult |
44 |
44 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
124 |
117 |
$1K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$662.40 |