| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
645 |
645 |
$43K |
| D0330 |
Panoramic radiographic image |
453 |
453 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
193 |
56 |
$10K |
| D1110 |
Prophylaxis - adult |
85 |
85 |
$8K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
12 |
12 |
$6K |
| D1206 |
Topical application of fluoride varnish |
329 |
329 |
$5K |
| D0350 |
|
352 |
108 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
27 |
27 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
548 |
237 |
$2K |
| D9430 |
|
39 |
38 |
$1K |
| D1120 |
Prophylaxis - child |
14 |
14 |
$735.00 |
| D0274 |
Bitewings - four radiographic images |
26 |
26 |
$280.80 |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$180.00 |
| D0270 |
|
12 |
12 |
$60.00 |