| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
248 |
247 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
217 |
216 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
124 |
61 |
$8K |
| D1320 |
|
233 |
232 |
$3K |
| D1120 |
Prophylaxis - child |
58 |
58 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
17 |
$2K |
| D1206 |
Topical application of fluoride varnish |
105 |
105 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
12 |
$1K |
| D4910 |
|
12 |
12 |
$924.00 |
| D9430 |
|
16 |
15 |
$512.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
109 |
29 |
$481.95 |
| D1310 |
|
29 |
29 |
$230.00 |
| D0350 |
|
87 |
18 |
$0.00 |