| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
70 |
28 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
119 |
119 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
12 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
23 |
23 |
$1K |
| D1110 |
Prophylaxis - adult |
19 |
19 |
$850.82 |
| D0220 |
Intraoral - periapical first radiographic image |
78 |
75 |
$815.24 |
| D1208 |
Topical application of fluoride, excluding varnish |
34 |
34 |
$592.72 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$368.81 |