| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9430 |
|
1,335 |
1,099 |
$42K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
619 |
619 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
502 |
269 |
$33K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
628 |
246 |
$32K |
| D1110 |
Prophylaxis - adult |
363 |
362 |
$32K |
| D0210 |
Intraoral - complete series of radiographic images |
451 |
451 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
234 |
234 |
$18K |
| D1120 |
Prophylaxis - child |
124 |
124 |
$6K |
| D1206 |
Topical application of fluoride varnish |
227 |
227 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
36 |
25 |
$3K |
| D0350 |
|
188 |
61 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
76 |
76 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
234 |
64 |
$935.55 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$156.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$144.00 |