| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4341 |
|
116 |
35 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
75 |
40 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
70 |
70 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
45 |
45 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
14 |
$2K |
| D1110 |
Prophylaxis - adult |
33 |
33 |
$1K |
| D0274 |
Bitewings - four radiographic images |
17 |
17 |
$493.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$455.00 |
| D0120 |
Periodic oral evaluation - established patient |
14 |
14 |
$392.00 |
| D0220 |
Intraoral - periapical first radiographic image |
24 |
24 |
$312.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
14 |
$126.00 |