| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
70 |
42 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
76 |
44 |
$7K |
| D1120 |
Prophylaxis - child |
212 |
212 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
222 |
222 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
200 |
200 |
$3K |
| D1110 |
Prophylaxis - adult |
38 |
38 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
61 |
60 |
$2K |
| D1206 |
Topical application of fluoride varnish |
72 |
72 |
$1K |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
28 |
$854.00 |
| D0603 |
|
71 |
71 |
$649.65 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$182.88 |