| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4346 |
|
401 |
399 |
$170.00 |
| D0274 |
Bitewings - four radiographic images |
657 |
655 |
$138.46 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
220 |
97 |
$112.00 |
| D0120 |
Periodic oral evaluation - established patient |
350 |
350 |
$108.00 |
| D0220 |
Intraoral - periapical first radiographic image |
872 |
863 |
$63.00 |
| D0330 |
Panoramic radiographic image |
302 |
299 |
$38.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
224 |
221 |
$24.00 |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
67 |
67 |
$0.00 |