| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9430 |
|
1,056 |
776 |
$33K |
| D0220 |
Intraoral - periapical first radiographic image |
854 |
706 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,254 |
675 |
$8K |
| D1110 |
Prophylaxis - adult |
90 |
88 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
405 |
400 |
$5K |
| D4910 |
|
58 |
57 |
$4K |
| D2954 |
|
37 |
13 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
73 |
72 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
82 |
81 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
120 |
120 |
$3K |
| D1120 |
Prophylaxis - child |
105 |
103 |
$3K |
| D0350 |
|
77 |
52 |
$2K |
| D0240 |
|
27 |
27 |
$540.00 |
| D0272 |
Bitewings - two radiographic images |
41 |
40 |
$390.00 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$280.80 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$221.50 |