| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
323 |
143 |
$14K |
| D1110 |
Prophylaxis - adult |
411 |
409 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
235 |
118 |
$12K |
| D0274 |
Bitewings - four radiographic images |
413 |
411 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
462 |
460 |
$9K |
| D0330 |
Panoramic radiographic image |
166 |
164 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
513 |
510 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
350 |
350 |
$3K |
| D1351 |
Sealant - per tooth |
80 |
13 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
79 |
79 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
30 |
30 |
$491.91 |
| D1310 |
|
59 |
59 |
$322.61 |
| D1330 |
|
58 |
58 |
$318.24 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$272.11 |
| D0603 |
|
12 |
12 |
$120.00 |