| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
130 |
130 |
$8K |
| D0350 |
|
263 |
219 |
$7K |
| D9430 |
|
185 |
144 |
$6K |
| D1110 |
Prophylaxis - adult |
39 |
39 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
62 |
62 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
41 |
24 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
195 |
118 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
139 |
139 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
34 |
18 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
13 |
13 |
$1K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$360.00 |