| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
514 |
474 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
570 |
172 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
384 |
146 |
$25K |
| D1110 |
Prophylaxis - adult |
515 |
479 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
504 |
461 |
$17K |
| D0274 |
Bitewings - four radiographic images |
474 |
442 |
$14K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
85 |
33 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
414 |
387 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
47 |
15 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$996.00 |
| D0120 |
Periodic oral evaluation - established patient |
40 |
39 |
$609.00 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
13 |
$195.00 |