| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
44 |
29 |
$5K |
| D1120 |
Prophylaxis - child |
101 |
101 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
105 |
105 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
101 |
101 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
13 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$1K |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$250.00 |