| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
419 |
227 |
$29K |
| D1110 |
Prophylaxis - adult |
584 |
576 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
619 |
605 |
$15K |
| D1206 |
Topical application of fluoride varnish |
658 |
644 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
205 |
129 |
$12K |
| D0274 |
Bitewings - four radiographic images |
374 |
368 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
271 |
232 |
$8K |
| D0330 |
Panoramic radiographic image |
203 |
202 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
82 |
58 |
$6K |
| D1120 |
Prophylaxis - child |
187 |
178 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
111 |
107 |
$3K |
| D0272 |
Bitewings - two radiographic images |
30 |
30 |
$543.33 |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
15 |
$192.40 |