| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
148 |
73 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
82 |
45 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
213 |
155 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
205 |
205 |
$4K |
| D1120 |
Prophylaxis - child |
127 |
127 |
$4K |
| D1110 |
Prophylaxis - adult |
80 |
80 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
201 |
201 |
$3K |
| D0330 |
Panoramic radiographic image |
57 |
57 |
$3K |
| D0274 |
Bitewings - four radiographic images |
50 |
50 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
65 |
62 |
$915.85 |
| D0272 |
Bitewings - two radiographic images |
18 |
18 |
$304.56 |