| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
32 |
21 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
63 |
61 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
23 |
16 |
$2K |
| D0274 |
Bitewings - four radiographic images |
68 |
64 |
$2K |
| D1110 |
Prophylaxis - adult |
28 |
28 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
54 |
50 |
$585.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
28 |
28 |
$513.00 |
| D9630 |
|
29 |
26 |
$428.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$420.00 |
| D0603 |
|
37 |
34 |
$352.00 |
| D1330 |
|
46 |
43 |
$240.00 |