| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
59 |
24 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
33 |
17 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
41 |
40 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
55 |
16 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
49 |
48 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
27 |
24 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
12 |
$0.00 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
60 |
15 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
44 |
44 |
$0.00 |
| D0330 |
Panoramic radiographic image |
35 |
35 |
$0.00 |
| D1110 |
Prophylaxis - adult |
33 |
32 |
$0.00 |