| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
113 |
49 |
$4K |
| D1110 |
Prophylaxis - adult |
112 |
111 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
168 |
166 |
$2K |
| D1120 |
Prophylaxis - child |
104 |
102 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
282 |
272 |
$2K |
| D0274 |
Bitewings - four radiographic images |
106 |
105 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
292 |
223 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
112 |
111 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
57 |
56 |
$1K |
| D0272 |
Bitewings - two radiographic images |
57 |
56 |
$682.11 |
| D0140 |
Limited oral evaluation - problem focused |
26 |
25 |
$394.45 |
| D1999 |
|
159 |
146 |
$0.00 |