| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
63 |
26 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
112 |
100 |
$3K |
| D0330 |
Panoramic radiographic image |
59 |
49 |
$2K |
| D1354 |
|
59 |
14 |
$2K |
| D1120 |
Prophylaxis - child |
89 |
78 |
$2K |
| D1206 |
Topical application of fluoride varnish |
97 |
86 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
41 |
26 |
$1K |
| D0272 |
Bitewings - two radiographic images |
53 |
43 |
$786.80 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$510.00 |