| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
402 |
387 |
$24K |
| D9430 |
|
194 |
168 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
145 |
131 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
68 |
24 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
493 |
185 |
$2K |
| D1110 |
Prophylaxis - adult |
26 |
24 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
13 |
$1K |
| D0350 |
|
185 |
64 |
$662.40 |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$660.00 |
| D0220 |
Intraoral - periapical first radiographic image |
55 |
55 |
$635.00 |
| D1206 |
Topical application of fluoride varnish |
34 |
32 |
$510.50 |