| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
400 |
400 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
130 |
129 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
76 |
40 |
$8K |
| D1110 |
Prophylaxis - adult |
54 |
54 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
26 |
15 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
15 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
54 |
24 |
$432.52 |
| D0220 |
Intraoral - periapical first radiographic image |
36 |
36 |
$353.88 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$353.76 |