| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
13 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
36 |
36 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
63 |
39 |
$725.13 |
| D1120 |
Prophylaxis - child |
19 |
19 |
$698.25 |
| D1208 |
Topical application of fluoride, excluding varnish |
39 |
39 |
$529.20 |
| D0220 |
Intraoral - periapical first radiographic image |
43 |
43 |
$514.96 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$280.56 |
| D0603 |
|
14 |
14 |
$0.00 |
| D0602 |
|
15 |
15 |
$0.00 |