| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
366 |
364 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
355 |
350 |
$17K |
| D0350 |
|
1,659 |
368 |
$12K |
| D1110 |
Prophylaxis - adult |
122 |
122 |
$11K |
| D9430 |
|
152 |
121 |
$5K |
| D0250 |
|
167 |
142 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
34 |
12 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
171 |
168 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
394 |
103 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
34 |
30 |
$408.00 |
| D0270 |
|
16 |
15 |
$80.00 |