| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
85 |
85 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
64 |
64 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
12 |
$1K |
| D0350 |
|
17 |
15 |
$416.40 |
| D0230 |
Intraoral - periapical each additional radiographic image |
15 |
15 |
$324.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$128.00 |