| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
78 |
47 |
$3K |
| D1110 |
Prophylaxis - adult |
83 |
83 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
107 |
107 |
$2K |
| D0274 |
Bitewings - four radiographic images |
102 |
102 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
202 |
109 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
185 |
170 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
103 |
85 |
$1K |
| D9994 |
|
17 |
17 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
12 |
$0.00 |