| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,207 |
210 |
$122K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
314 |
73 |
$25K |
| D2332 |
|
43 |
20 |
$5K |
| D1120 |
Prophylaxis - child |
135 |
135 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
285 |
285 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
101 |
101 |
$2K |
| D0330 |
Panoramic radiographic image |
56 |
56 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
55 |
55 |
$2K |
| D0272 |
Bitewings - two radiographic images |
36 |
36 |
$820.11 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$635.04 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$467.46 |
| D0230 |
Intraoral - periapical each additional radiographic image |
39 |
13 |
$430.71 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$157.29 |
| D0603 |
|
165 |
164 |
$0.00 |