| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4910 |
|
107 |
97 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
69 |
26 |
$7K |
| D1110 |
Prophylaxis - adult |
143 |
141 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
150 |
141 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
220 |
200 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
94 |
84 |
$3K |
| D0274 |
Bitewings - four radiographic images |
52 |
49 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
26 |
24 |
$431.20 |