| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
74 |
32 |
$9K |
| D1120 |
Prophylaxis - child |
73 |
73 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
69 |
69 |
$2K |
| D1206 |
Topical application of fluoride varnish |
62 |
62 |
$1K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$594.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$462.00 |
| D0220 |
Intraoral - periapical first radiographic image |
24 |
24 |
$398.81 |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
16 |
$339.00 |