| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
173 |
172 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
245 |
243 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
74 |
42 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
101 |
50 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
571 |
184 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
95 |
88 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
22 |
14 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
260 |
237 |
$1K |
| D0272 |
Bitewings - two radiographic images |
87 |
87 |
$966.35 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
13 |
$394.47 |
| D4355 |
|
15 |
13 |
$43.26 |