| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
230 |
230 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
197 |
84 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
180 |
180 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
144 |
56 |
$8K |
| D1110 |
Prophylaxis - adult |
70 |
70 |
$6K |
| D0350 |
|
422 |
113 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
104 |
103 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
41 |
41 |
$489.00 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$257.50 |