| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
238 |
238 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
230 |
107 |
$15K |
| D0330 |
Panoramic radiographic image |
336 |
336 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
188 |
188 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
52 |
24 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
20 |
13 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
12 |
$1K |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$1K |
| D9430 |
|
39 |
38 |
$1K |
| D1206 |
Topical application of fluoride varnish |
66 |
66 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
110 |
58 |
$441.45 |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
15 |
$180.00 |
| D0350 |
|
44 |
12 |
$0.00 |