| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
168 |
51 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
300 |
295 |
$8K |
| D1120 |
Prophylaxis - child |
258 |
253 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
304 |
297 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
112 |
80 |
$5K |
| D1110 |
Prophylaxis - adult |
45 |
43 |
$2K |
| D0330 |
Panoramic radiographic image |
34 |
30 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
32 |
28 |
$1K |
| D0272 |
Bitewings - two radiographic images |
29 |
29 |
$441.52 |