| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
53 |
27 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
157 |
150 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
31 |
15 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
109 |
106 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
89 |
85 |
$1K |
| D1110 |
Prophylaxis - adult |
27 |
27 |
$910.00 |
| D0272 |
Bitewings - two radiographic images |
14 |
12 |
$216.00 |