| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
188 |
182 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
171 |
165 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
29 |
12 |
$2K |
| D1110 |
Prophylaxis - adult |
41 |
41 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
13 |
$1K |
| D1999 |
|
24 |
22 |
$732.65 |
| D0251 |
|
180 |
175 |
$98.06 |
| D1206 |
Topical application of fluoride varnish |
26 |
26 |
$10.95 |
| D0220 |
Intraoral - periapical first radiographic image |
26 |
26 |
$0.00 |