| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
453 |
155 |
$55K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
149 |
54 |
$26K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
102 |
27 |
$14K |
| D1110 |
Prophylaxis - adult |
287 |
267 |
$13K |
| D0330 |
Panoramic radiographic image |
224 |
210 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
700 |
644 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
494 |
465 |
$11K |
| D0274 |
Bitewings - four radiographic images |
306 |
284 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
307 |
284 |
$10K |
| D1206 |
Topical application of fluoride varnish |
507 |
480 |
$9K |
| D1120 |
Prophylaxis - child |
289 |
270 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
630 |
531 |
$5K |
| D0272 |
Bitewings - two radiographic images |
106 |
95 |
$2K |
| D1351 |
Sealant - per tooth |
65 |
13 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
35 |
30 |
$970.15 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13 |
12 |
$329.28 |