| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
26 |
13 |
$1K |
| D1110 |
Prophylaxis - adult |
47 |
47 |
$883.93 |
| D0274 |
Bitewings - four radiographic images |
43 |
42 |
$192.48 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
29 |
29 |
$104.23 |
| D1208 |
Topical application of fluoride, excluding varnish |
45 |
45 |
$99.45 |
| D0220 |
Intraoral - periapical first radiographic image |
47 |
46 |
$28.14 |
| D0230 |
Intraoral - periapical each additional radiographic image |
44 |
43 |
$18.06 |