| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
505 |
505 |
$33K |
| D0210 |
Intraoral - complete series of radiographic images |
397 |
397 |
$19K |
| D1110 |
Prophylaxis - adult |
199 |
199 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
127 |
49 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
300 |
300 |
$4K |
| D2330 |
|
35 |
12 |
$3K |
| D4341 |
|
32 |
13 |
$2K |
| D4910 |
|
26 |
26 |
$2K |
| D9430 |
|
38 |
37 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
13 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
13 |
13 |
$945.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$144.00 |