| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,359 |
842 |
$136K |
| D1110 |
Prophylaxis - adult |
1,463 |
1,463 |
$72K |
| D0120 |
Periodic oral evaluation - established patient |
1,846 |
1,846 |
$42K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
422 |
259 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,513 |
1,513 |
$24K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
641 |
558 |
$21K |
| D0274 |
Bitewings - four radiographic images |
712 |
712 |
$19K |
| D1120 |
Prophylaxis - child |
322 |
322 |
$11K |
| D1206 |
Topical application of fluoride varnish |
607 |
606 |
$10K |
| D0330 |
Panoramic radiographic image |
214 |
213 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
34 |
27 |
$4K |
| D0272 |
Bitewings - two radiographic images |
157 |
157 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$182.00 |