| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
678 |
674 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
206 |
175 |
$19K |
| D0274 |
Bitewings - four radiographic images |
657 |
654 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
810 |
806 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
174 |
151 |
$14K |
| D0330 |
Panoramic radiographic image |
277 |
276 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
913 |
905 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
618 |
615 |
$4K |
| D1351 |
Sealant - per tooth |
41 |
19 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
69 |
68 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
46 |
46 |
$744.48 |
| D1120 |
Prophylaxis - child |
38 |
38 |
$536.83 |
| D1310 |
|
86 |
86 |
$430.00 |
| D1330 |
|
86 |
86 |
$430.00 |
| D0603 |
|
36 |
36 |
$350.00 |
| D0601 |
|
23 |
23 |
$230.00 |