| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
33 |
14 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
30 |
28 |
$565.12 |
| D1208 |
Topical application of fluoride, excluding varnish |
45 |
42 |
$382.20 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$367.50 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$242.27 |
| D0230 |
Intraoral - periapical each additional radiographic image |
19 |
15 |
$92.08 |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
15 |
$75.36 |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
13 |
$70.64 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$63.78 |
| D0603 |
|
73 |
71 |
$0.00 |