| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
78 |
30 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
52 |
50 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
48 |
38 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
41 |
38 |
$558.60 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$484.54 |
| D0220 |
Intraoral - periapical first radiographic image |
40 |
38 |
$477.28 |
| D1120 |
Prophylaxis - child |
14 |
14 |
$404.25 |
| D0603 |
|
82 |
80 |
$0.00 |