| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
363 |
158 |
$28K |
| D1110 |
Prophylaxis - adult |
170 |
170 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
152 |
152 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
170 |
170 |
$3K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$755.86 |
| D1120 |
Prophylaxis - child |
16 |
16 |
$536.32 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$438.34 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$215.04 |
| D0220 |
Intraoral - periapical first radiographic image |
17 |
16 |
$0.00 |
| D2332 |
|
16 |
12 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
21 |
15 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
24 |
14 |
$0.00 |