| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
121 |
75 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
69 |
51 |
$5K |
| D1120 |
Prophylaxis - child |
172 |
172 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
187 |
166 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
225 |
225 |
$4K |
| D1110 |
Prophylaxis - adult |
82 |
82 |
$3K |
| D0272 |
Bitewings - two radiographic images |
140 |
140 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
148 |
148 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
26 |
26 |
$366.34 |