| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
68 |
68 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
39 |
13 |
$3K |
| D0350 |
|
253 |
53 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
35 |
35 |
$2K |
| D9430 |
|
14 |
14 |
$448.00 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$390.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
53 |
28 |
$214.65 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$191.00 |