| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
33 |
16 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
79 |
79 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
30 |
13 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
182 |
102 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
121 |
103 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
76 |
76 |
$940.80 |
| D1120 |
Prophylaxis - child |
20 |
20 |
$661.50 |
| D0350 |
|
69 |
32 |
$441.12 |
| D0274 |
Bitewings - four radiographic images |
16 |
16 |
$380.71 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$280.56 |
| D0603 |
|
148 |
143 |
$0.00 |