| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
118 |
49 |
$7K |
| D1120 |
Prophylaxis - child |
82 |
82 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
142 |
142 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
12 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
72 |
72 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
89 |
88 |
$972.45 |
| D0230 |
Intraoral - periapical each additional radiographic image |
97 |
88 |
$884.32 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$404.70 |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$305.94 |
| D0603 |
|
29 |
29 |
$0.00 |