| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
256 |
158 |
$28K |
| D1120 |
Prophylaxis - child |
320 |
320 |
$12K |
| D1206 |
Topical application of fluoride varnish |
418 |
418 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
377 |
377 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
25 |
$3K |
| D1110 |
Prophylaxis - adult |
26 |
26 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$697.34 |
| D0220 |
Intraoral - periapical first radiographic image |
46 |
45 |
$689.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
15 |
13 |
$154.00 |