| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
268 |
107 |
$24K |
| D9920 |
|
134 |
130 |
$9K |
| D1120 |
Prophylaxis - child |
210 |
208 |
$7K |
| D1206 |
Topical application of fluoride varnish |
204 |
202 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
219 |
218 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
106 |
92 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
14 |
$2K |
| D1110 |
Prophylaxis - adult |
26 |
25 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
38 |
27 |
$1K |
| D0272 |
Bitewings - two radiographic images |
38 |
37 |
$765.70 |
| D0240 |
|
48 |
26 |
$588.96 |
| D9994 |
|
170 |
166 |
$471.96 |
| D0220 |
Intraoral - periapical first radiographic image |
153 |
133 |
$421.37 |