| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
303 |
303 |
$20K |
| D9430 |
|
302 |
287 |
$10K |
| D1110 |
Prophylaxis - adult |
54 |
54 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
54 |
30 |
$4K |
| D0274 |
Bitewings - four radiographic images |
157 |
157 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
205 |
204 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
172 |
163 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
27 |
27 |
$810.00 |
| D1120 |
Prophylaxis - child |
14 |
14 |
$735.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
96 |
70 |
$388.80 |