| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9430 |
|
2,176 |
1,778 |
$69K |
| D0120 |
Periodic oral evaluation - established patient |
660 |
660 |
$44K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
478 |
476 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
1,716 |
1,464 |
$20K |
| D1120 |
Prophylaxis - child |
502 |
500 |
$20K |
| D1206 |
Topical application of fluoride varnish |
1,026 |
1,022 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,167 |
1,288 |
$14K |
| D1110 |
Prophylaxis - adult |
140 |
139 |
$12K |
| D0274 |
Bitewings - four radiographic images |
496 |
492 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
97 |
97 |
$5K |
| D4341 |
|
39 |
12 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
40 |
25 |
$3K |