| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9430 |
|
713 |
598 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
219 |
219 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
90 |
27 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
147 |
147 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
124 |
124 |
$6K |
| D1120 |
Prophylaxis - child |
63 |
62 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
603 |
215 |
$2K |
| D4910 |
|
29 |
29 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
95 |
94 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
75 |
72 |
$900.00 |
| D1206 |
Topical application of fluoride varnish |
50 |
50 |
$655.50 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$280.80 |