| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
404 |
184 |
$76K |
| D9920 |
|
386 |
322 |
$50K |
| D0350 |
|
942 |
895 |
$47K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
303 |
120 |
$47K |
| D1120 |
Prophylaxis - child |
829 |
790 |
$42K |
| D1206 |
Topical application of fluoride varnish |
1,133 |
1,076 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
799 |
738 |
$28K |
| D0140 |
Limited oral evaluation - problem focused |
288 |
259 |
$16K |
| D0272 |
Bitewings - two radiographic images |
297 |
286 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
223 |
199 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
25 |
13 |
$7K |
| D1110 |
Prophylaxis - adult |
129 |
116 |
$3K |
| D0274 |
Bitewings - four radiographic images |
37 |
37 |
$2K |
| D0602 |
|
1,079 |
989 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
19 |
19 |
$0.00 |