| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,208 |
1,026 |
$289K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,342 |
964 |
$153K |
| D1206 |
Topical application of fluoride varnish |
1,237 |
1,202 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
834 |
821 |
$19K |
| D1120 |
Prophylaxis - child |
387 |
379 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
386 |
376 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
58 |
40 |
$10K |
| D0330 |
Panoramic radiographic image |
175 |
174 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
275 |
264 |
$9K |
| D1351 |
Sealant - per tooth |
325 |
91 |
$8K |
| D9920 |
|
130 |
104 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
19 |
12 |
$205.26 |