| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
188 |
66 |
$18K |
| D2335 |
|
90 |
28 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
70 |
45 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
118 |
117 |
$6K |
| D1110 |
Prophylaxis - adult |
72 |
72 |
$5K |
| D0330 |
Panoramic radiographic image |
49 |
49 |
$4K |
| D2332 |
|
27 |
12 |
$4K |
| D1351 |
Sealant - per tooth |
80 |
17 |
$3K |
| D2330 |
|
22 |
13 |
$2K |
| D1206 |
Topical application of fluoride varnish |
23 |
23 |
$678.04 |
| D1120 |
Prophylaxis - child |
15 |
15 |
$573.30 |
| D0220 |
Intraoral - periapical first radiographic image |
59 |
57 |
$570.14 |
| D0230 |
Intraoral - periapical each additional radiographic image |
57 |
40 |
$560.20 |