| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
521 |
167 |
$50K |
| D0330 |
Panoramic radiographic image |
376 |
375 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
198 |
79 |
$25K |
| D1110 |
Prophylaxis - adult |
448 |
446 |
$24K |
| D1120 |
Prophylaxis - child |
552 |
552 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
467 |
466 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
677 |
677 |
$19K |
| D1352 |
|
250 |
40 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
724 |
724 |
$17K |
| D0274 |
Bitewings - four radiographic images |
297 |
296 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
170 |
170 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
24 |
12 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
170 |
170 |
$3K |
| D4355 |
|
12 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
87 |
41 |
$890.38 |