| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
314 |
128 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
159 |
79 |
$14K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
115 |
28 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
80 |
36 |
$10K |
| D1110 |
Prophylaxis - adult |
176 |
168 |
$10K |
| D1351 |
Sealant - per tooth |
233 |
26 |
$7K |
| D0274 |
Bitewings - four radiographic images |
188 |
170 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
172 |
143 |
$6K |
| D0330 |
Panoramic radiographic image |
110 |
92 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
185 |
180 |
$5K |
| D1120 |
Prophylaxis - child |
82 |
79 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
163 |
156 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
88 |
79 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
80 |
55 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
163 |
129 |
$2K |