| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
168 |
167 |
$8K |
| D0330 |
Panoramic radiographic image |
277 |
271 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
131 |
126 |
$3K |
| D1120 |
Prophylaxis - child |
110 |
109 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
14 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
98 |
98 |
$616.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
87 |
27 |
$392.85 |
| D9430 |
|
12 |
12 |
$336.00 |
| D0350 |
|
33 |
14 |
$234.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$144.00 |