| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
458 |
457 |
$30K |
| D0210 |
Intraoral - complete series of radiographic images |
351 |
349 |
$16K |
| D9430 |
|
414 |
389 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
131 |
74 |
$9K |
| D4341 |
|
53 |
15 |
$4K |
| D1110 |
Prophylaxis - adult |
32 |
32 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
350 |
172 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
12 |
$1K |
| D0350 |
|
258 |
90 |
$1K |
| D1206 |
Topical application of fluoride varnish |
37 |
37 |
$590.00 |
| D0330 |
Panoramic radiographic image |
32 |
32 |
$495.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$175.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$144.00 |