| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
379 |
165 |
$33K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
218 |
107 |
$25K |
| D1120 |
Prophylaxis - child |
677 |
677 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
827 |
827 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
940 |
940 |
$13K |
| D0330 |
Panoramic radiographic image |
278 |
278 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
92 |
47 |
$10K |
| D1110 |
Prophylaxis - adult |
244 |
244 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
141 |
75 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
275 |
268 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
238 |
235 |
$7K |
| D0274 |
Bitewings - four radiographic images |
229 |
229 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
365 |
362 |
$5K |
| D0272 |
Bitewings - two radiographic images |
227 |
227 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
97 |
97 |
$3K |
| D7111 |
|
31 |
20 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
91 |
73 |
$641.55 |