| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9430 |
|
3,032 |
2,293 |
$97K |
| D0120 |
Periodic oral evaluation - established patient |
1,149 |
1,143 |
$80K |
| D1120 |
Prophylaxis - child |
1,683 |
1,671 |
$75K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
686 |
685 |
$45K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,000 |
1,538 |
$37K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
317 |
174 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,231 |
1,224 |
$15K |
| D0274 |
Bitewings - four radiographic images |
664 |
662 |
$14K |
| D1206 |
Topical application of fluoride varnish |
536 |
526 |
$12K |
| D2160 |
|
110 |
67 |
$9K |
| D1310 |
|
146 |
146 |
$7K |
| D1351 |
Sealant - per tooth |
212 |
52 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
81 |
80 |
$4K |
| D0272 |
Bitewings - two radiographic images |
252 |
249 |
$3K |
| D7111 |
|
40 |
24 |
$2K |
| D9993 |
|
25 |
25 |
$2K |
| D0602 |
|
51 |
51 |
$750.00 |
| D1203 |
|
12 |
12 |
$0.00 |