| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
50 |
31 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
40 |
30 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
139 |
139 |
$4K |
| D1110 |
Prophylaxis - adult |
65 |
65 |
$3K |
| D1120 |
Prophylaxis - child |
85 |
85 |
$3K |
| D1206 |
Topical application of fluoride varnish |
135 |
135 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
16 |
12 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
55 |
54 |
$2K |
| D0274 |
Bitewings - four radiographic images |
51 |
51 |
$2K |
| D0330 |
Panoramic radiographic image |
21 |
21 |
$1K |
| D1351 |
Sealant - per tooth |
34 |
14 |
$1K |
| D0272 |
Bitewings - two radiographic images |
51 |
51 |
$1K |