| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
559 |
559 |
$37K |
| D1110 |
Prophylaxis - adult |
372 |
372 |
$33K |
| D9430 |
|
747 |
647 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
468 |
468 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
331 |
183 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
447 |
446 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
121 |
66 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,013 |
300 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
37 |
28 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
12 |
12 |
$815.00 |
| D0220 |
Intraoral - periapical first radiographic image |
64 |
62 |
$768.00 |